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Full text of "A Practical compendium of midwifery : being the course of lectures on midwifery, and on the diseases of women and infants, delivered at St. Bartholomew's Hospital"



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GOOCH'S PRACTICAL COMPENDIUM of MIDWIFERY. 



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XXlii 



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A PRACTICAL DICTIONARY OF 
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By JOHN BELL, M.D., 

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PRACTICAL 

COMPENDIUM OF MIDWIFERY; 



BEING THE COURSE OF 



LECTURES ON MIDWIFERY, 



THE DISEASES OF WOMEN AND INFANTS, 

DELIVERED AT 

ST. BARTHOLOMEWS HOSPITAL, 

BY THE LATE 

ROBERT GOOCH, M.D. 



PREPARED POR PUBLICATION 

BY GEORGE SKINNER, 

MEMBER OF THE ROYAL COLLEGE OF SURGEONS, LONDON. 



THIRD AMERICAN EDITION. 



HASWELL, BARRINGTON, AND HASWELL 

NEW YORK: J. & H. G. LANGLEY. 

NEW ORLEANS: JOHN J. HASWELL & CO. 

1840. 



■* 



PREFACE. 



The editor of this volume attended the Lectures 
on Midwifery, delivered at St. Bartholomew's Hos- 
pital, by the late Dr. Gooch. In common with many 
other pupils he took notes of these lectures ; and that 
with a minuteness which comprised the most trifling 
particulars. The abilities of the late Dr. Gooch are 
now so justly and so highly appreciated, that it would 
be superfluous to say anything in recommendation 
of instructions proceeding from such a teacher. 

The divisions of the work will, perhaps, be thought 
at first sight not unexceptionable. But it was found 
impracticable to adopt any other, which would dis- 
tinguish the several subjects by appropriate titles, 
without departing greatly from the original plan of 
the lectures. This plan has been adhered to as 
strictly as possible : the author's terms and expres- 
sions have been retained whenever these were pecu- 
liar or characteristic, and on all occasions his meaning: 
has been reserved with the most scrupulous fidelity. 

A few Notes are added, chiefly for the purpose of 
introducing such illustrations as may be afforded by 
the editor's own experience, and of remarking upon 
any modes of practice which have been proposed or 



8 PREFACE. 

revived since the time when these lectures were de- 
livered. 

For any faults of which the editor himself is not 
conscious, he claims the indulgence of the public ; 
trusting that the care and pains with which the work 
has been prepared for publication, will be sufficiently 
apparent to form an apology. 

It may be proper to add, that these lectures are 
published with the consent of the executor of the 
late Dr. Gooch, and that the conditions of their pub- 
lication are such, that his family have an interest in 
their success. 



CONTENTS 



LECTURE I. 

ON THE NATURAL FUNCTIONS, AND ON THE DISEASES OF THE 
FEMALE ORGANS OF GENERATION. 

PAG E 

Section I. — On Menstruation, 13 

II. — Diseases of the Female Organs of Gener- 
ation, ...... 18 

(a) Chlorosis, . . . . . . . .18 

(b) Amenorrhea, or Suppression of the Menses, . 24 

(c) Obstructed Menstruation, . . . . .27 

(d) Dysmenorrhea, or Painful Menstruation, . . 29 

(e) Menorrhagia, or Profuse Menstruation, . . 32 

(f ) Leucorrhcea, or Fluor Albus, . . . .40 

(g) Final Cessation of the Menses, . . . .44 

(h) Pruritus Pudendi, ...... 45 

(i ) Furor Uterinus, . . . . . . .47 

(k) Imperforate Hymen, ...... 48 

(1 ) Malformed Vagina, ...... 51 

(m) Lacerated Perinaeum. Sloughing of the Soft 

Parts, &c. . . . . .52 

(n) Polypus Uteri, 55 

(o) Procidentia Uteri, ...... 62 

(p) Chronic Inflammation of the Uterus, . . .69 
(q) Cancer Uteri, . . . . . , .70 

(r) Ovarian Dropsy, 74 



10 CONTENTS. 



LECTURE II. 

ON PREGNANCY. 

PAGE 

Section I. — Theory of Conception, . . . .78 

II.— The Gravid Uterus, .... 86 

III.— Position of the Child in Utero, . . 98 

IV. — Of the Signs of Pregnancy, . . .99 

. V. — Diseases of Pregnancy, . . . .106 

VI. — Retro versio Uteri, . . . . .116 

VII.— On Abortion, 122 

LECTURE III. 

ON LABOUR. 

Section I. — Natural Labour, 132 

II. — On the Management of the Placenta, . 149 

LECTURE IV. 
ON difficult labour. 

Section I. — On Impeded Labour, .... 174 

(a) On the Injuries arising from Protracted Labour, . 189 

(b) On the Employment of the Forceps, . . . 193 

. 205 
. 206 
. 211 
. 214 
. 214 



(c) On the Employment of the Vectis, 

(d) On Craniotomy, 

(e) On Artificial Premature Labour, 

(f ) Section of the Symphysis Pubis, 

(g) The Caesarian Section, 



CONTENTS. 



11 



PAGE 

Section II. — On Preternatural Presentations, . . 217 

(a) On the Presentation of the Feet, . . .218 

(b) On the Presentation of the Breech, . . .219 

(c) On the Presentation of the Arm, . . . 222 

(d) On the Presentation of the Funis, . . . 228 

Section III. — Of Complicated Labour, . . . 230 

(a) Of Puerperal Convulsions, 230 

(b) Of Haemorrhage before the Birth of the Child, . 236 

(c) Plurality of Children, 245 

(d) Rupture of the Uterus, 248 



ON THE GENERAL MANAGEMENT OF WOMEN AFTER DELIVERY, 
AND ON THE TREATMENT OF THE COMMON AFFECTIONS IN- 
CIDENT TO THE PUERPERAL STATE. 

Section I. — General Management of Women after de- 
livery, . . . . . 254 



II. — After-pains, . 
III.— Diet, 

IV. — Unfavourable Nipples, . 
V. — Excoriation of the Nipples, 
VI. — Mammary or Milk Abscess, 



. 255 
. 256 
. 260 
. 261 
. 264 



LECTURE VI. 

ON THE DISEASES OF WOMEN AFTER DELIVERY. 

Section I. — On Puerperal or Child-bed Fever, . 
II. — On Inflammation of the Uterus, 
III. — On Puerperal Mania, 



. 267 
. 276 

. 277 



12 



CONTENTS. 



PAGE 



Section IV.— Phlegmasia Alba Dolens Puerperarura ; 

or, the Swelled Leg of Lying-in 
Women, 283 

V. — Inversion of the Uterus, . . ' . • 286 



LECTURE VII. 



ON THE GENERAL MANAGEMENT, ON THE MALFORMATIONS, 
AND ON THE DISEASES OF INFANTS. 



Section I. — General Management of Infants, 
II. — Malformation of Infants, . 

(a) Hare-lip, 

(b) Defects of the Umbilicus, . 

(c) Closed Labia Pudendi, 

(d) Imperforate Urethra in the Male Infant, 

(e) Imperforate Anus, 

(f ) Spina Bifida, . 

(g) Contorted feet, &c, 

Section III. — Diseases of Infants, 

(a) Diarrhoea, . 

(b) Watery Gripes, . 

(c) Chronic Diarrhoea, . 

(d) Convulsions, .... 

(e) Disorders connected with Dentition, 

(f ) Infantile Remittent Fever, . 

(g) Croup, ..... 
(h) Spasmodic Croup, 



293 

299 

299 
§00 
301 
302 
302 
304 
305 

306 

306 
308 
309 
310 
313 
318 
320 
322 



PRACTICAL 
COMPENDIUM OF MIDWIFERY. 



LECTURE THE FIRST. 

ON THE NATURAL FUNCTIONS, AND ON THE DISEASES 
OF THE FEMALE ORGANS OF GENERATION. 

Section I. — On Menstruation. 

I have first to describe the functions of the female 
sexual organs in their healthy state, and then their 
morbid deviations. 

The genital organs of the female child, are very 
different from those of the adult. The uterus of a 
child is about the size of the little finger ; its parietes 
are thin and pallid. The ovaries, also, are very small in 
comparison with those of the adult, which latter are 
as large as a pigeon's egg. The sexual organs in 
children are not only small, but they perform no 
function, pour out no menstrual fluid, excite no pas- 
sion ; and if the act of coition should take place, no 
conception would follow. Although the girl may 
have attained the size of a full grown woman, the 
sexual organs continue diminutive, and exercise no 

3 



14 DISEASES OF FEMALE ORGANS OF GENERATION. 

function until the age of puberty. At this period 
they undergo a considerable change, both as to de- 
velopment and function ; the external appearance of 
the female is much altered ; and if you have not seen 
her for some months, you remark how womanly she 
is become ; her pelvis is enlarged, her breasts are full, 
and there is a general rotundity of the body. These 
appearances do not continue long before she feels a 
fulness in her head and breasts, pain, weight, and 
dragging- sensation about the loins and in the region 
of the uterus, with a hot skin, and a rapid pulse. 
These symptoms evidently arise from local irritation 
in the uterus ; they will subside without being fol- 
lowed by any discharge ; but in a short time they 
recur, and continue for a few hours, when there issues 
from the vulva a fluid, which at first appears like 
water tinged with blood ; but after a few ounces 
have been discharged, it becomes of a redder colour, 
and then ceases ; when the above symptoms subside 
and are succeeded by a sense of languor and faint- 
ness. This is the mode of the first occurrence of 
menstruation. At the end of some months the same 
symptoms return ; and being repeated at some few 
periods menstruation is established ; this process re- 
curring, with almost mechanical regularity, every 
month, unless pregnancy, nursing, or certain diseases, 
interrupt the natural functions. 

The period of life during which menstruation takes 
place, is from about the age of fifteen to that of forty- 
five ; some diseases do not interrupt it. 

In the commencement, menstruation is generally 
attended with the before-mentioned symptoms ; but 
as the regularity of the function becomes established, 
the disturbance of the system, at the periods of its 
recurrence, diminishes. That it is about to take 
place, is generally known a few hours previously by 
a slight sense of fulness and tightness about the head, 
together with a sense of fulness with shooting pains 
in the breasts. There is also a great susceptibility 



ON MENSTRUATION, 15 

of the nervous system, manifested by flushing of the 
face upon any slight emotion. Physiologists have 
endeavoured to explain the menstrual function ; but 
the development of the organs which produce it has 
been sometimes overlooked. It has been said, that 
the moon has an influence on its occurrence ; but if 
such were the case, all women would menstruate at 
the same time, making a sort of universal flood-tide ; 
but as some or other women are menstruating every 
day, we may give up this notion of lunar influence. 
That this process depends upon plethora, seems also 
an objectionable explanation. They say, that a wo- 
man arrives at her full size, before which time there 
was a call for a supply of blood for the purpose of 
growth, which having attained its limits, the re^ 
dundant quantity must be disposed of in some other 
way; and hence the menstrual evacuation. But men 
and animals also attain their full growth ; this doctrine, 
founded on a supposed superfluity of blood, equally 
applies to them ; yet they do not menstruate. 

More modern physiologists say that, on the full de- 
velopment of the ovaries and uterus, the menstrual 
discharge commences. This discharge has by some 
been thought to proceed from the vagina, but during 
pregnancy, when the os tineas is hermetically sealed, 
it does not occur. Sometimes, indeed, menstruation 
takes place during pregnancy ; but we must not draw 
our conclusions from one case out of a thousand, but 
from nine hundred and ninety-nine out of a thousand. 
In procidentia uteri the menstrual fluid has been 
seen issuing guttatim from the os tineas. This, Dr. 
William Hunter has clearly shown : and if you ask 
females who are troubled with this complaint, whence 
the fluid comes, they say from the chink at the bot- 
tom of the tumour. Further proof has been obtained 
by examination after death. I was present at the 
examination of the body of a female who died of tris- 
mus ; two days prior to her death she began to menr 
struate, and died while the menses were on her. J 



16 DISEASES OF FEMALE ORGANS OF GENERATION. 

examined the uterus, and found a substance like cur- 
rant jelly adhering to its inner membrane. From 
these facts it is sufficiently obvious that the menstrual 
fluid is poured out by certain vessels which termi- 
nate on the inner surface of the uterus. Morgagni 
perceived the mouths of these vessels in the uterus 
of a woman who was hanged during menstruation. 

The quantity of fluid evacuated at each period 
varies in different females and in different climates. 
In cold northern regions it is scanty ; in this climate, 
moderate ; in warm climates, profuse. It is very dif- . 
ficult to ascertain either by weight or measurement 
the precise quantity of this discharge. De Haen 
made inquiries among poor women, and found that 
they only used one cloth, which, when wet, was 
dried and applied again. He then took a similar 
napkin, dipped it in blood, dried it, and immersed it 
again. This experiment he repeatedly tried; and 
from it he deduces that from four to eight ounces, 
rarely ten, and most commonly about six ounces, of 
fluid are lost at each period of menstruation. We 
call it blood ; it is of the colour of blood, but has not 
all its properties; for blood invariably coagulates 
when at rest in the interior of the body. Even in 
aneurism it will coagulate, forming layer upon layer 
on the sides of the aneurismal sac ; and impeding 
the passage of blood through the vessel, sometimes, 
by its accumulation, effects a spontaneous cure. But 
if the menstrual fluid be retained for months, or years, 
as it is in cases of imperforate hymen, it does not 
coagulate. In this case the fluid is still prepared, 
but does not escape externally. It is gradually aug- 
mented to an enormous quantity; at length the nature 
of the disease is discovered, the distended hymen is 
punctured; and quarts, perhaps, of the menstrual 
fluid are discharged, not coagulated, but of the con- 
sistence of treacle, differing from blood only by con- 
taining a smaller proportion of the coagulating prin- 
ciple. It has been thought, both by civilized and 



ON MENSTRUATION. 17 

savage nations, that this fluid possess poisonous quali- 
ties, of a kind so virulent or peculiar, that, if a men- 
struating woman walked three times round a garden, 
all the flowers would be blighted and the caterpillars 
killed ; and the belief of its poisonous nature has pre- 
vailed among nations holding no intercourse by which 
it may be communicated from one to the other. A 
North American said, that if the saliva of a menstrua- 
ting virgin were smeared on the bronchocele of a 
male, it would cure it. Females, in countries where 
these notions prevail, are separated during menstrua- 
tion from the males, who carry their superstition in 
this matter so far, that, if the pipe should fall from 
the hand of a man who was smoking it, and be , 
broken, the accident would be imputed to its having 
been lighted at the hut of a menstruating woman. 

The time of the first appearance of the menses 
varies in different climates. The usual period of the 
commencement of menstruation in this country is 
about the age of fourteen ; in colder climates, as 
among the Laplanders, its first occurrence is so late * 
as twenty ; and near the equator, so early as nine or 
ten years of age. A Dutch traveller says, that in 
Japan he saw a number of little girls with children 
either in their arms, or at their breasts ; their juve- 
nile appearance, contrasted with their maternal oc- 
cupation, was very striking. At Java, females are 
married when only nine or ten years of age. 

In this country at about the age of forty-five the 
function of the uterus is nearly at an end. The dis- 
charge begins to grow scanty in quantity, and irre- 
gular in its returns, and at length entirely ceases. 
At this time the breasts diminish, the ovaries become 
smaller, the uterus is contracted to almost a schirrous 
hardness, the sensitive and conceptive functions are 
wanting; and thus the state essentially resembles 
that before puberty. After this period women very 
seldom conceive. Having thus described the func- 



18 DISEASES OF FEMALE ORGANS OF GENERATION. 

tions of the female sexual organs in their healthy 
state, I am now to treat of their morbid peculiarities. 



Section II. — Diseases of the Female Organs of 

Generation. 



(a) CHLOROSIS. 

If in girls who have attained the age at which this 
change is customary the sexual organs are not de- 
veloped, a deranged state of the constitution occurs, 
characterized by peculiar symptoms. You may re- 
mark in a girl at the age of puberty who does not 
menstruate, or but imperfectly, a waxy, tumid face, 
disordered digestive organs, palpitating heart on the 
slightest exertions, debility and indolence, with an 
inactive mind and disturbance of the nervous system, 
as cedematous face at the breakfast-table, and at night 
cedamatous ankles, a gradual subsidence of the swel- 
ling of the face as the day advances, and a depraved, 
though not deficient, appetite. To these symptoms 
are added a torpid state of the bowels, with perhaps 
clay-coloured evacuations. These symptoms consti- 
tute what is called chlorosis, or retention of the 
menses.-^n addition to the other circumstances just 
enumerated, the quality of the circulating fluid is, in 
those cases, altered ; blood has been taken by way of 
experiment, and it has been found to be of a pale red 
colour, and watery, like the juice of a cherry. 

With respect to the pathology of chlorosis, the 
theory which has obtained a most extensive credit is 
that of Dr. Cullen ; but it is perfectly groundless. 
Comparing the circumstances attendant on the de- 
velopment of the sexual organs at the usual period, 
with those when their customary development does 
not take place, he says that the body is healthy, and 
grows up naturally until puberty, but that it will go 

)mu^~*^ f sfry J Ttr*^ a^^OUr^ J ********; ^t^Ac^g * 



CHLOROSIS. 19 

no farther without the aid of the stimulus of the sexual 
organs, of which he considers the ovaries to be the 
most important : so that, if these are developed and 
active, the natural state of health proceeds ; if not, the 
whole system sutlers, and the symptoms just mention- 
ed are the consequence of such derangement. A man, 
or other animal, if deprived of the testes by castration, 
will become puffy, flabby, indolent, and relaxed, from 
an absence of the stimulus supplied by these organs ; 
consequences somewhat resembling the state of chh> 
rosis in the female from an undeveloped state of the 
sexual organs. In opposition to this view I have to 
remark, that Mr. Pott, when operating on a woman 
for strangulated hernias, (one on each side,) cut off 
the ovaries, which were contained in either hernial 
sac, thus spaying her to all intents and purposes. 
According to Dr. Cullen's theory she should have 
fallen into chlorosis ; but she did not ; she became 
muscular and hairy, with a hoarse voice, and a mas- 
culine appearance. I knew the case of a female 
whose sexual organs at the age of puberty remained 
undeveloped ; her breasts were flat, and the external 
organs of generation as small as those of a child ; her 
appetite was bad, she ate but a penny roll in a week, 
and had a stool about once in a fortnight ; at the age 
of twenty-eight, she was about four feet high, and 
had no passions common to her sex. She ceased to 
grow at ten years of age, and at twenty-eight died of 
some affection of her chest. On examination, her 
ovaries and uterus were found as small as those of 
an infant ; instead of becoming chlorotic from this 
diminutive state of these organs, she merely wanted 
the feelings natural to her sex. 

The theory which appears to me the most expla- 
natory and rational is, that chlorosis depends on a 
want of that constitutional vigour by which the sexual 
organs may be brought into action ; that to this de- 
ficiency may be imputed the failure both of their 
development and functions. At the period of puberty 



20 DISEASES OF FEMALE ORGANS OF GENERATION. 

the constitution has not only itself to nourish, but it 
must have energy to rouse and excite to action a new 
set of organs ; it must supply the materials for an 
increase of their growth, and all other purposes inci- 
dent to their function. 

I would ask who are the subjects of chlorosis ? 
Are they the robust, florid, active, and vigorous fe- 
males ? No ; in such the menstrual function is com- 
monly established in the most favourable manner. 
The puny and delicate females are most disposed to 
it, who, before the age of puberty, could scarcely 
support the existing state of the system which of 
course must be inadequate to supply any additional 
demand. This view of the pathology of chlorosis at 
once suggests the general design of cure, and derives 
confirmation from the success of the means employed 
for this end. 

Chlorotic patients, although the disease under 
which they suffer may continue for months, or even 
years, if properly placed and treated will perhaps 
generally recover, though not all with equal ra- 
pidity. 

The disease may terminate fatally by serous effu- 
sion into the chest, or other cavities of the body, ac- 
companied by general oedema; or tubercles proceed- 
ing to suppuration may form in the lungs ; and the 
patient may thus be destroyed either by dropsy or 
phthisis. Stupor of mind, despondency, and nervous 
irritation, may end in hypochondriasis and insanity. 
I knew a young lady labouring under chlorosis, who 
was about to be married ; it was intended that the 
marriage should take place as soon as possible. The 
house was purchased, &c, but the nervous irri- 
tability incident to her complaint was so excited by 
the occasion, that she became insane, and still remains 
so. Such terminations are rare, but phthisis and 
serous effusions are not uncommon. 

In the treatment of this disease we must consult 
our experience, in order to know what objects are to 






CHLOROSIS 21 

be attained ; and this will suggest principally three 
indications. — First, to improve the state of the diges- 
tive organs, and consequently the general health. Se- 
condly, to palliate symptoms. Thirdly, to excite the 
sexual organs by local stimulants. An emetic is 
sometimes given in the commencement, for the pur- 
pose of clearing the stomach of all irritating contents ; 
and as the tongue is foul, the alimentary canal torpid, 
and the secretions unnatural, a purgative should also 
be administered. The emetijp should consist of ipe- 
cacuanha, and the purgative of rhubarb, or aloes, 
with calomel. This purgative should be of an effect- 
ual kind ; and after two or three repetitions of it the 
dose may be moderated ; as by giving one grain of 
calomel with four or five of aloes every other night, 
for about ten days or a fortnight, when the digestive 
functions will most probably be in an improved state, 
the alimentary canal will be cleared of its irritating 
contents, the secretions will be more natural, the 
tongue will be clean, and the appetite less depraved. 
You then give some slight tonics; as infusion of 
quassia with lime water, or the infusion of casca- 
rilla with the subcarbonate of soda as an antacid. 
These remedies may, for some time, be employed in 
conjunction with the laxative plan ; and the stomach 
and bowels having been brought into a healthy state, 
those remedies may be administered which promise 
more permanent benefit, such as different prepara- 
tions of iron ; still, however, in conjunction with 
so much aloes as will produce two evacuations every 
day. For example, six grains of the sulphate of iron, 
or twelve grains of the carbonate, with five or six 
grains of the watery extract of aloes, made into six 
or eight pills, may be given daily, in divided portions, 
with a light but nutritive diet of animal food, wine 
or porter, together with pure air. If living in a 
town or city, the patient must go into the country ; 
regular exercise must be taken daily, by walking, 
riding, or dancing ; the two latter are to be preferred. 

4 



22 DISEASES OF FEMALE ORGANS OF GENERATION. 

The effect of exercise in this complaint is such that 
the complaint is sometimes cured by it alone ; but 
without the aid of exercise, medical skill will be un- 
availing. 

A lady who was extremely indolent, whose hands 
were always cold, &c, had exhausted the resources 
of her medical attendants, having gone through the 
regular routine of medicines without benefit. I 
ordered her bread pills, and made her go to a riding- 
school daily, and ride until she got into a complete 
glow of heat, — until the coldness of her hands was 
exchanged for warmth and perspiration. I told her 
that if she ever went to bed without having thus rid- 
den during the day, she must say with the wise man, 
" Perdidi diem,'' 1 - — I have lost a day. She used this 
horse exercise, took her bread pills, and was cured of 
her chlorosis by exercise alone. 

With respect to dancing, there are many girls 
who cannot walk the shortest distance without fatigue 
and violent palpitation of the heart, who can go to a 
ball and dance all night without much inconvenience. 
This is said to be owing to the agreeable sensations 
excited by the touch of their partner's hand, by 
which the benefit of the exercise is rendered more 
certain. During the recovery of such patients symp- 
toms of congestion about the head will arise now and 
then ; if so, do not attempt to relieve these symptoms 
by bleeding, but apply cold to the temples and head, 
omit the use of steel, and give the sulphuric acid, in 
any way most convenient, until the symptoms sub- 
side, when the exhibition of the steel may be re- 
sumed. 

When effusion has taken place into the cavities of 
the body, occasioning difficult breathing, attended by 
oedema, and a scanty secretion of urine, diuretics are 
the most efficacious remedies : and of these the most 
reliance maybe placed on digitalis, of which ten 
drops of the tincture, with twenty of nitrous aether, 
may be given three times a day. This medicine, 






CHLOROSIS. 23 

by promoting the secretion of urine, relieves the 
breathing and other symptoms so successfully that 
Dr. Hamilton, who was much struck with its effects, 
recommends it as the most effectual remedy in all the 
stages of chlorosis ; supposing this disease to depend 
on a weakened state of the lymphatic system, which 
is stimulated by this combination into a healthy 
activity. Dr. Hamilton prescribes one part of the 
tincture of digitalis with two parts of nitrous aether ; 
of which mixture thirty drops are to be given every 
hour, until a copious secretion of urine is produced. 
This evacuation being once excited to a considerable 
amount, he then keeps up an action both on the kid- 
neys and bowels, by administering such doses of 
emetic tartar as may be borne without sickness every 
six hours. After continuing this treatment for three 
weeks he then recommends the tonic remedies, such 
as steel, aloetic and stomachic bitters, &c. If vertigo 
or syncope should occur during the use of digitalis, 
Dr. Hamilton states that it is effectually relieved * by 
the use of the warm bath. 

This treatment having been some time continued, 
the general health will be improved ; good blood will 
be freely propelled into every part of the system, the 
uterus will be adequately supplied with this fluid, 
and menstruation will most probably occur. This 
consequence does not, however, always succeed to a 
restoration of the general health ; in this stage, there- 
fore, half a drachm of madder, taken three times a 
day, is said by some to be beneficial ; or a drachm 
of the tincture of black hellebore, three times a day, 
as recommended by Dr. Mead. In this state, also, 
are to be used those remedies which topically stimu- 
late the uterus, such as electricity, or a husband.* 
If menstruation does not take place when the function* 

* Among other local experiments the employment of stimulating 
pessaries was an occasional practice in former times : more recently- 
stimulating injections have been recommended with a similar 
view. 



24 DISEASES OF FEMALE ORGANS OF GENERATION. 

of the digestive organs is natural, and the general 
health improved, I would try electricity. You gene- 
rally find, that although the patient does not men- 
struate, she experiences pains in the loins, headache, 
shooting pains in the breast, &c, at the customary 
intervals of menstruation; profiting by an oppor- 
tunity of this kind we must pass slight electric 
shocks through the pelvis; this has succeeded on 
the second day of its use, and the female has felt the 
blood issuing from the pudenda even before she had 
time to quit the room. As to matrimony, where so 
agreeable an expedient can be resorted to, it is a very 
effectual remedy. When a woman, in whom the 
menstrual evacuation has been scanty and irregular, 
is married, this discharge will in general become 
profuse, unless it is altogether interrupted by preg- 
nancy. The too early excitement of the sexual organs 
by onanism will produce a state of the system re- 
sembling that of chlorosis. 



(b) AMENORRHEA, OR SUPPRESSION OF THE MENSES. 

A woman may have passed over that period of life 
when chlorosis is likely to occur, and menstruation 
may have been established very regularly for months 
or years, when from certain causes its return at the 
usual period may be prevented, or the discharge may 
be suddenly checked when it has actually taken 
place. An interruption of either kind may in general 
be attributed either to mental emotion, or to the ap- 
plication of cold. 

We are continually witnessing effects of these 
causes on the functions of the sexual organs. Sud- 
den terror, or any other passion, will not only check 
the secretion of milk, but will alter its quality ; for 
if a child sucks under such circumstances it 'will 
be griped. It is an ascertained fact among the ass- 
breeders, that if the foal dies and another is invested 



AMENORRHEA, ETC. 25 

in its skin, and introduced to the mother as her own 
progeny, the milk will be freely secreted so long as 
the deception continues : 'but on her discovering the 
cheat, the secretion of milk immediately ceases. — 
This proves that mental agitation has a powerful 
influence over the function of one part of the sex- 
ual system, and it will also affect not less power- 
fully the function of the uterus. I was prescribing 
for a French lady labouring under a suppression of 
the menses, and on questioning her, found that she 
had not menstruated since the Cossacks entered 
Paris ; and it was a well authenticated circumstance 
that, at the time the allied armies entered Paris, 
from a similar mental emotion, a great number of 
French ladies were thus affected. The French jour- ' 
nals of the day contained long lists of patients la- 
bouring under this disease. The effect of cold on 
the uterus during menstruation, about the time of 
its occurrence, is a matter of familiar experience ; 
and it is to this influence that the suppression of 
the menses is, perhaps, the most frequently to be im- 
puted. 

How do these causes operate ? On some occa- 
sions they seem to excite an inflammatory action 
in the uterus, and they act on others by produc- 
ing spasm : difference dependant upon the idiosyn- 
crasies of different individuals. If a young unmar r 
ried woman of full habit, with a red face, fleshy, and 
robust, be exposed to these causes, the consequent 
cessation of the discharge is followed by pains in 
the head and back, a sense of weight, pain, and ten- 
sion about the region of the uterus, which is also 
tender on pressure, together with a hot skin and rapid 
pulse. Here the attack seems to be of an inflamma- 
tory nature. But when females of a delicate habit, 
haying an irritable nervous system, are subjected to 
a similar influence, the consequences are, irritation 
and spasm of the uterus, rather than inflammatory 
disease — for the pain is not continued, the uterus is 



26 DISEASES OF FEMALE ORGANS OF GENERATION. 

not tender on pressure, the pulse is neither rapid nor 
full, and the skin is not hot ; on the contrary, there 
is a general sense of chilliness, and the feet are par- 
ticularly cold. 

If proper remedies are employed, the disease will 
in general be cured ; but this success is by no means 
invariable. A young female, fleshy and full of blood, 
got very wet during menstruation ; the discharge 
was suppressed, to which succeeded headache, a hot 
skin, and rapid pulse, pain and tenderness in the 
region of the uterus, &c. : physicians were consulted, 
but she died, and on examination the uterus was 
found in a state of mortification, the result of intense 
inflammation. 

The treatment of this disease must be adapted to 
the variety of it under which a patient suffers. If of 
the inflammatory kind, which would be denoted by 
the presence of febrile symptoms, together with con- 
tinued pain and tenderness in the region of the uterus, 
it must be treated by such bleedings, both general 
and local, as by leeches, as the violence of the symp- 
toms may demand, and by all those other means 
comprised in the antiphlogistic plan. By such 
treatment the inflammatory action will most proba- 
bly be subdued; and on its subsidence, the menstrual 
discharge will be renewed, and proceed in the cus- 
tomary manner. 

But supposing a suppression of this kind occurs 
in one of the other class of females ; here we shall 
obtain more benefit from that which is termed the 
antispasmodic, than from the antiphlogistic plan ; 
but in this case it is proper to purge, and that smartly. 
Put the patient into the warm hip. bath, administer 
diluent drinks, and give antispasmodics, such as five 
grains of pulv. ipecac, comp. and three grains of 
camphor, every four hours, until all the symptoms 
subside. The injection of antispasmodic remedies, 
such as laudanum, or asafcetida, into the rectum, 
will sometimes act like a charm ; — in the latter I have 



OBSTRUCTED MENSTRUATION. 27 

great faith ; let two drachms of asafoetida be rubbed 
down with the yolk of an egg, and mixed with six 
ounces of warm water ; this mixture should be gra- 
dually injected up the rectum, which being done, a 
napkin should be closely applied to the part, and 
every means made use of in order to secure its re- 
tention. If you use laudanum, let the vehicle be 
small in quantity ; an injection of this kind may 
consist of fifty or sixty drops of laudanum in three 
ounces of water. It is a great error to suppose the 
benefit is to be in proportion to the quantity of fluid 
injected ; this may be true to some extent of purging 
injections, but the quantity of those of the anodyne 
description should be small, both because the active 
ingredient is less diluted, and the injection is the 
more likely to be retained. The spasmodic affection 
having yielded, and the nervous irritation allayed, 
menstruation generally ensues. But it may so hap- 
pen, that when the state of spasm has ceased in one 
varietv of the disease, and that of inflammation in the 
other, the menstrual discharge may still not super- 
vene. Its recurrence may then be expected at the 
next period ; but if it should be suspended month 
after month, and year after year, this state is distin- 
guished as that of obstructed menstruation. 



(c) OBSTRUCTED MENSTRUATION. 

By this expression is meant a chronic suppression 
of the menses, produced, perhaps, originally by one 
or other of the causes before mentioned, and continued 
from some peculiar derangement of the system, the 
pathology of which is too obscure to be easily under- 
stood. 

In this country practitioners regard obstructed 
menstruation as the consequence of constitutional 
disturbance ; while the patients themselves, instruct- 
ed by the elder authorities among their own sex, 



28 DISEASES OF FEMALE ORGANS OF GENERATION. 

entertain a contrary belief. The females who suffer 
chronic obstruction of the menses are of two classes : 
in one there is a preternatural fulness of vessels, 
with headache, pain in the back and loins,*ja full, 
strong, and rapid pulse, together, perhaps, with 
symptoms of incipient pulmonary disease, as flushed 
cheeks, pain in the chest, a short dry cough, &c. ; 
in the other, agreeably with the difference of temper- 
ament, there may be remarked only disorder of the 
digestive organs, great nervous irritation, a small 
quick pulse, cold feet, and a sallow countenance. 

When a woman menstruates regularly and natu- 
rally the system obtains the relief of an adequate 
periodical excretion ; but if the uterus, from deficient 
vigour, does not perform its natural function of 
secretion, there will be a plethora, of which the symp- 
toms just mentioned are the consequence : hence 
benefit is obtained from those remedies which lessen 
the quantity of the circulating fluids. 

If the state of obstructed menstruation continues 
long, the patient will suffer from disorder of the diges- 
tive organs, with torpor of the whole system, more 
especially of the sexual organs ; her appearance will 
be leucophlegmatic, and her condition will resemble 
that of chlorosis. 

The remedies employed for the cure of this disease 
must be appropriate to the constitution of those in 
whom it occurs. If it arises from excess of blood, 
we must lessen it by a spare diet, saline laxatives 
which operate three or four times a day ; and con- 
gestion about the head or lungs must be relieved by 
the occasional abstraction of blood. Under this plan 
of treatment the symptoms will commonly subside, 
and menstruation will occur. 

But if the patient is of the weak and nervous tem- 
perament the treatment will be similar to that directed 
for the cure of chlorosis. The bowels should be 
regularly evacuated by aperients ; and the system 
should be invigorated by tonics, by nutritive diet, 



DYSMENORRHEA, ETC. 29 

regular exercise, and pure air. The constitution 
being restored to a more healthy state, the uterus 
will generally resume its functions ; but if it does 
not, yo.u must now have recourse to those local stimu- 
lants for exciting the action of the uterus formerly 
recommended for the cure of chlorosis. But let this 
always be remembered, that the state of mere ob- 
structed menstruation is to be carefully distinguished 
from that of pregnancy. 



(d) DYSMENORRHEA, OR PAINFUL MENSTRUATION. 

Women sometimes suffer, at the time of menstrua- 
tion, pains in the back and uterus, shooting pains in 
the breasts, with sense of fulness and tightness in 
the head : these symptoms precede the discharge, 
and continue during the first few hours after its oc- 
currence ; but may diminish as the discharge pro- 
ceeds, and before it has terminated cease entirely. 
These symptoms are not uncommon in those who 
menstruate favourably ; but they are designated by 
the term dysmenorrhea only when they are of unusual 
severity, when the pain is extremely violent both in 
the loins and above the symphysis pubis, accompanied 
with excessive tightness about the head, and with 
weakness of the knees. These symptoms precede 
the discharge a few hours ; abate, and finally cease, 
as it flows more freely. In these cases flakes, or 
little masses, which, when washed, are found to be 
coagulable lymph, are mixed with the discharge; 
and sometimes this substance is thrown off apparently 
as a membrane which had lined the cavity of the 
uterus. 

In this complaint the discharge is in general 
scanty ; but it may be deficient at first, and after 
continuing for a time may become so profuse as to 
occasion considerable debility. Women labouring 
under this disease are barren. We look around and 

5 



30 DISEASES OF FEMALE ORGANS OF GENERATION. 

see many young married women whose appearance 
affords the promise of fecundity who, nevertheless, 
have no children. This failure is a source of wonder 
and regret with those whom it chiefly concerns ; and 
on inquiry it would be found to be generally, though 
by no means invariably, owing to the disordered 
actions incident to dysmenorrhcea. 

The causes of this disease are three : the first and 
most common is a feeble, nervous, and irritable con- 
stitution ; the second may be plethora, characterized 
by a red face, full, strong pulse, &c. ; the third is a 
disordered state of the digestive organs, or disease of 
the abdominal viscera. The pain will vary in dif- 
ferent subjects : in some it may be of the inflamma- 
tory kind, accompanied with a hot, dry skin, rapid, 
full pulse, headache, and tenderness of the uterus ; 
in others, with perhaps an equal degree of pain, 
though not of the same kind, — there will be cold 
feet, but neither a full pulse, nor tenderness of the 
uterus. 

In the treatment of this disease there are princi- 
pally two indications ; the first, to alleviate the pain 
during the menstrual period : and the second, to 
employ between the intervals of menstruation such 
remedies as will prevent its recurrence. The first 
intention is easily accomplished ; but the second, if 
at all, with great difficulty. If the uterus is tender 
on pressure, with a hot skin, rapid pulse, &c, the 
existence of an inflammatory state of the uterus is 
denoted. In this case the hip bath must be used, 
abstinence from animal food and fermented liquors 
must be directed, together with a vegetable diet, 
diluents and purgative medicines ; and blood must 
be abstracted, if the inflammatory state is such as to 
require it. By these means the pain will be dimi- 
nished, and the uterus will be disposed to a more 
healthy action. 

In females of a weak, nervous constitution,- gentle 
laxatives, together with anodynes, may be given with 



DYSMENORRHEA, ETC. 31 

advantage on the first occurrence of the symptoms: 
the use of the hip bath may also be extremely bene- 
ficial. 

In order to prevent the recurrence of dysmenor- 
rhea, if the abdominal viscera are disordered, you 
must endeavour, by a treatment upon general princi- 
ples, to restore them to a healthy state. If plethora 
be the cause, you must reduce the quantity of the 
circulating fluid by vegetable diet, saline laxatives, 
and by the abstraction of blood about once a month. 
If there is debility, you must strengthen the system 
by the metallic tonics, as steel, and sulphuric acid 
combined with the sulphate of zinc ; by pure air and 
gentle exercise ; — these are the principal indications 
of treatment. 

There are some practitioners who regard this 
disease as one always of an inflammatory nature, 
and in this view their treatment is little better than 
empirical. It consists, they say, of chronic inflam- 
mation of the uterus; and knowing the power of 
mercury in curing chronic inflammation of the liver, 
the eye, and other organs, they immediately put the 
system under its influence, by giving a grain of calo- 
mel with opium, or the extract of hemlock, every 
night, until the gums become a little tender. Others, 
assuming, also, that the disease is always inflam- 
matory, (for the reasons that the pain is permanent, 
that there is a sense of fulness and tenderness in the 
region of the uterus, and that flakes of coagulated 
lymph are mixed with the discharge,) prescribe in- 
discriminately that course of treatment which is 
termed antiphlogistic, consisting of bleedings, ab- 
stinence from animal food and fermented liquors, 
together with a vegetable diet, purgatives, &c. This 
treatment is proper only in that form of the disease 
which is dependant on plethora, the instances of 
which are by far the most rare. Dr. Dewees com- 
menced with the antiphlogistic plan; by which, he 
said, he relieved many, but cured none. From con- 



32 DISEASES OF FEMALE ORGANS OF GENERATION. 

sidering that the structure of the uterus was chiefly 
muscular, he was induced to believe dysmenorrhoea 
analogous in its nature to chronic rheumatism. 
Agreeably with this view of its pathology, on the 
commencement of the pain he gave ten grains of 
camphor, and repeated this dose in two hours if the 
pain was not diminished; in this treatment he per- 
severed until menstruation proceeded without pain. 
In the interval between the menstrual periods he 
gave a drachm of the volatile tincture of guaiacum 
three times a day in a glass of white wine, from 
which treatment considerable benefit is experienced 
in chronic rheumatism; he then gradually increased 
the dose till three drachms of the tincture were taken 
three times a day for perhaps three months. Of the 
good effects of camphor I can myself speak with con- 
fidence. It seems to act specifically on the uterus, 
affording considerable relief; but it should not be 
given when the disease is of the inflammatory kind, 
in which it may be prejudicial. Dr. Dewees con- 
siders the volatile tincture of guaiacum no less a 
specific for dysmenorrhoea, than for the cure of ob- 
structed menstruation. When obstructed menstrua- 
tion occurs in a female of a plethoric habit, florid 
complexion, full pulse, &c, this remedy, being too 
great a stimulus, is objectionable; but when the sys- 
tem is torpid and inactive, as is common in chlorosis 
and in chronic obstruction of the menses, it is not 
only unobjectionable, but may be used with great 
advantage; though I cannot as yet regard it as a 
specific. 



(e) MENORRHAGIA, OR PROFUSE MENSTRUATION. 

The menstrual discharge, instead of being inter- 
rupted, may be increased to such an excess, that the 
loss of so much fluid may produce extreme debility, 
and prove highly injurious to the constitution. This 



MENORRHAGIA, ETC. 33 

irregularity is termed menorrhagia ; but writers make 
a distinction;. dividing it into profuse menstruation, 
and' menorrhagia ; meaning by the first an increase 
of the customary discharge, and by the second, a 
haemorrhage similar to that which may occur from 
any other part of the system. If the recurrence of 
the discharge is at the usual periods, the disease is 
merely excess of menstruation; if more frequently, 
menorrhagia. The distinction, however, between 
merely an excess of the uterine function, and actual 
haemorrhage, is not in all cases easily made. 

If this disease has existed a considerable time, the 
body suffers from the drain on the sanguineous sys- 
tem. For want of the usual supply of blood, the 
face becomes bleached, the patient has nervous head- 
aches, the pain of which is confined to one spot, 
vertigo, singing in the ears, drowsiness ; the body is 
chilly, the hands and feet cold, the heart acts feebly 
on small quantities only of .blood at each systole, and 
the pulse consequently is small and languid. This 
disordered state of the brain is owing to a deficiency 
of the natural supply of blood, and is very similar 
to that which arises from too great a supply of this 
fluid. A person threatened with apoplexy has head- 
ache, vertigo, noise in the ears, &c, the cause of 
which symptoms is an excess of blood. The same 
sensations may be felt by a woman who has only half 
the usual quantity of blood sent to the brain : she 
feels as if she were always in danger of falling ; this 
sensation occurs even on suddenly turning her head; 
and if it were not immediately and cautiously re- 
turned to its natural position, it is probable she really 
would fall; thus experiencing from deficiency of 
blood, the sensations which otherwise occur when 
an excess of this fluid is sent to the brain. 

There are two classes of females peculiarly dis- 
posed to menorrhagia. In the robust and plethoric, 
the disease is characterized by inflammatory symp- 
toms, as permanent pain, sense of fulness, weight, 



34 DISEASES OF FEMALE ORGANS OF GENERATION. 

and tenderness in the region of the uterus, together 
with a hot skin, and a full, hard, .febrile pulse. 
These are the symptoms of an active or acute dis- 
ease, which on the continent, is called inflammatory 
menorrhagia. In the other class of females, the 
disease is attended with no pain in the region of the 
uterus; there is a bleached countenance, a languid 
circulation, and a small, weak pulse : this is the 
chronic form of menorrhagia, or, as distinguished on 
the continent, menorrhagia from debility. Among 
those who suffer the acute form of menorrhagia, the 
symptoms are sometimes those of inflammation and 
sometimes those of spasmodic affection. Continental 
physicians, therefore, make spasmodic menorrhagia, 
or menorrhagia arising from irritation, a third variety 
of this complaint. The pain in this latter form is 
not constant, the discharge is not continued ; it sub- 
sides, and returns with throes resembling labour 
pains, and is accompanied with a quick, contracted 
and irritable pulse, which is that neither of inflam- 
mation nor debility. 

Thus we have three kinds of menorrhagia : the 
first is characterized by inflammatory symptoms ; the 
second by general debility, and probably a relaxed and 
passive state of the vessels of the uterus ; and the 
third by spasm and irritation. These differences 
must be borne in mind, for we are constantly liable 
to meet with them in our practice. Thus, a woman 
may menstruate at the regular periods, and the dis- 
charge may continue the usual time, yet it may flow 
with such rapidity that its amount may be more than 
double that which is customary. Or the discharge 
may occur at regular periods, and instead of con- 
tinuing three or four days as is natural, it may con- 
tinue ten, twelve, or fourteen days ; as in the former 
case, debility is produced by the rapidity of the dis- 
charge — in this, the same state is induced by its long 
continuance. Or, instead of being regular in its 
periods, it may recur as often as every two or three 



MENORRHAGIA, ETC. 35 

weeks ; and thus also the body is drained of its blood, 
and the system is debilitated. 

If the disease be of the active and inflammatory 
kind, we must keep the patient in a recumbent pos- 
ture on a sofa or mattress, prescribe a low, unirri- 
tating diet, together with such saline purgatives as 
will procure three or four evacuations daily. If there 
is a full, hard pulse, with a plethoric state of the 
system, treat it as you would a case of inflammation 
of any other organ, by copious venesection, and give 
such medicines as are likely to lower the circulation, 
as ten grains of the nitrate of potash with ten drops 
of the tincture of digitalis every six hours. Thus, by 
a recumbent posture, an unstimulating diet, saline 
laxatives, bleeding, nitre, and digitalis, the inflam- 
matory symptoms will be subdued, the hot skin will 
become cool, the pain and tenderness of the uterus 
will subside, and, as the system becomes tranquilized, 
the haemorrhage will cease. But this antiphlogistic 
treatment will not succeed in the spasmodic or irri- 
tative form of the complaint. It is difficult at the 
bed-side always to distinguish these two forms ; and 
if, on trial of the antiphlogistic means, no abatement 
of the symptoms takes place, we must have recourse 
to the antispasmodic remedies, which, after the failure 
of the former, will generally effect a cure. A lady 
labouring under this disease, which was thought to 
be of the acute kind, went through the whole routine 
of antiphlogistic remedies without any benefit. I 
then gave her one grain of ipecacuanha every hour : 
in eight hours she became nauseated and sick, and 
the discharge immediately ceased. I had only to keep 
up this state of nausea for a day or two, and the dis-. 
charge did not occur. When you have a case of 
menorrhagia, attended with a quick and irritable 
pulse, the pain subsiding and recurring, you maybe 
certain that it arises from spasm or irritation, and that 
it will be relieved by antispasmodic remedies. The 
two best are, ipecacuanha taken into the stomach, 



36 DISEASES OF FEMALE ORGANS OF GENERATION. 

and asafoetida with opium injected into the rectum 
A grain of ipecacuanha is to be given every hour till 
nausea is produced ■ which state must he maintained 
for a day or two, by repeating the same dose as fre- 
quently as may suffice for this purpose : and quiet 
local irritation in the uterus by injections of asafoetida 
or opium, as directed in dysmenorrhoea. There is a 
very marked connection between the pain and the 
discharge ; for if you can relieve the one, the other 
will cease. 

The acute and the spasmodic forms of this disease- 
are much more rare than that characterized by de- 
bility ; in nine cases of menorrhagia out of ten there 
is a feeble circulation, produced, probably, by the 
loss of blood, general debility, a relaxed state of 
the vessels of the uterus, a chilly state of the body, 
cold hands and feet, great irritability of the constitu- 
tion, with a disordered state of the stomach and 
bowels. Between the nervous system and the diges- 
tive organs there is this sort of connection, that when 
either is disturbed, the other participates m the de- 
rangement. The selection of a proper mode of treat- 
ment in this form of menorrhagia is of the utmost im- 
portance. Many practitioners will tell you to ad- 
minister such remedies as will strengthen and in- 
vigorate the system — take care of that, and let the 
discharge take care of itself. I do not consider this 
the best mode of treatment, but should rather say, 
take care of the discharge and let the system take 
care of itself, which it will do ; for, as you succeed 
in diminishing the discharge, the svstem will obtain 
a healthy proportion of its fluids, and the patient will 
gain all the advantages of an adequate nutrition. 
But on the contrary plan, while you are attempting 
to strengthen the constitution, the discharge will 
certainly be weakening it. A lady who went to 
India, was married there, and had seventeen children, 
with several miscarriages in addition. This rapid 
child-bearing produced a purely passive haemorrhage. 



MENORRHAGIA, ETC. 37 

She had a continual dropping for months from the 
uterus, which occasioned a cadaverous countenance, 
a cold, death-like state of the hands and feet, a small, 
weak pulse, and a nervous affection of the head. She 
had taken all kinds of tonics, steel, bark, acids ; she 
had tried country air, and the cold bath ; but all 
without success. When I first saw her, she was 
lying on a sofa, a striking spectacle, more like a 
corpse than a living person ; she said she was not 
glad to see me, for she had taken so much medicine 
with no effect that she was perfectly tired of it. I 
directed her to have injected every night half a pint 
of water into the rectum after she was in bed. She 
said she did not like it; I replied, " You will go on 
as you have done for weeks, and at length you will 
have recourse to my slighted remedy : you will then 
find its operation so speedy and so effectual, that you 
will exclaim, ' What a fool I was that I did not use 
it before !' " This representation had the desired ef- 
fect : she began to use this simple injection the same 
night. At first, the chill was just taken off the water ; 
gradually its temperature was reduced until it was 
used quite cold : and being herself satisfied of its effi- 
cacy, this injection was repeated every night and 
morning. She lay on a sofa during the day, and in 
nine or ten days the discharge ceased, which had re- 
sisted all other remedies during nine months. The 
drain from the system having ceased, the vessels 
became filled, and she regained her flesh and 
strength. 

In using this remedy, I would advise you to act 
with, caution when the weather is very cold. At 
first take the chill off the water, and, by degrees, use 
it cold ; but do not use it in the inflammatory or acute 
form of the complaint, or in that of the spasmodic 
and irritable kind, for in these it will be productive 
of mischief. If you use it in the description of cases 
to which I have alluded, I do not know so good a 
remedy ; but do not suppose that it will therefore 

6 



38 DISEASES OF FEMALE ORGANS OF GENERATION. 

cure others which are not of the same nature. In 
the passive menorrhagia, let your patient have pure 
air, together with the injections of cold water, and 
nutritive, but not stimulating diet ; let her take acids, 
bark, and steel, and keep the bowels relaxed. On 
the continent they use cinnamon as a tonic, and I 
have found it a good addition to the medicines of this 
kind which I usually prescribe. My common formula 
is a draught consisting of acid, sulph. dilut. gtt. xv., 
zinc, sulph. gr. j., tinct. cinnam. gtt. xxx., aq. menth. 
pip. §i. ; which is to be taken three times a day. 
Steel is sometimes useful, but on other occasions it 
quickens the pulse : the benefit, therefore, to be de- 
rived from this remedy can be known only by a trial 
of it. It has been recommended in this complaint to 
inject, with a syringe introduced into the mouth of 
the uterus, a decoction of pomegranate rind with alum; 
this treatment has been attended with success, but it 
should be employed with the greatest caution. This 
remedy was once tried under the direction of an 
eminent and skilful physician ; inflammation of 
the uterus came on in consequence, and the patient 
died. 

General directions for the treatment of menorrha- 
gia may be thus stated : — Let the diet be nutritious, 
but not stimulating; keep the bowels relieved by 
the use of gentle laxatives ; give tonic medicines ; 
employ local means, of which the injection of cold 
water into the rectum is the most efficacious. In 
administering an' enema it must not be propelled 
with great violence, for, the gut does not like to be 
thus assaulted, and will immediately reject it. Our 
object is that the injection should be retained ; there- 
fore it must be given when the patient is in bed. It 
must be pressed up gradually and gently, at first 
every night, and then every night and morning. 
The patient must remain on a sofa during the day, 
as the recumbent position is the most favourable. If 
it should be necessary to continue this remedy a 



MENORRHAGIA, ETC. 39 

long time, we must suspend the employment of it 
for a few days at the accustomed return of the men- 
strual period, and afterwards resume it. The benefit 
obtained from it is sometimes immediate ; but if the 
case should prove tedious, the disease will neverthe- 
less, in general, be ultimately cured by it. 

The profuse discharge so especially characteris- 
tic of menorrhagia may be in connection with other 
states than those formerly described : it may proceed 
from cancer of the uterus, from polypus, or from 
threatened abortion. It is not at all times easy, 
from a mere description of symptoms, to distinguish 
between those haemorrhages which arise from an 
altered structure of the uterus, and those incident to 
the common form of menorrhagia ; the nature of the 
case may, however, be discriminated by an exami- 
nation per vaginam. Cancer of the uterus is more 
common than is generally supposed ; and hemor- 
rhages resulting from this disease are often treated 
as those of common menorrhagia, when, perhaps, on 
the approach of a fatal termination an examination 
is made, and a large fungus, or else cancer, is disco- 
vered. Many women are pregnant, and do not know 
it; a haemorrhage takes place, and continues until 
the expulsion of the ovum is effected, when the hae- 
morrhage ceases. In the earliest part of my practice, 
I was called to a lady who had for a considerable 
time a dropping from the uterus, which had produced 
a bleached, cadaverous countenance, cold hands and 
feet, and great debility. On examination, I found at 
the upper part of the vagina a little, long, projecting 
tumour, which I thought might possibly be a pecu- 
liar formation of the cervix uteri. I was afterwards 
called in great haste to see her ; and on my entering 
her bed-room she said something was coming away ; 
and on examination I found the leg of a foetus in the 
vagina; I speedily delivered her of a foetus of about 
four months' growth; the placenta soon followed, 
and the haemorrhage ceased. This was a blunder 



40 DISEASES OF FEMALE ORGANS OF GENERATION. 

of mine : for that which I supposed to be the cervix 
uteri was no other than the foot of the foetus just 
beginning to protrude through the os tincse. A 
professional gentleman called on me one day, and 
said that his wife was in great pain, and was flood- 
ing profusely. I inquired if the discharge coagu- 
lated, and whether the pain resembled that of labour? 
On his replying in the affirmative to these questions, 
I said the case must be one of abortion, which the 
husband thought impossible, as his wife was not 
pregnant. I inquired whether menstruation occurred 
at the last period? The answer was " No ; but that 
is no guide, for she has not menstruated regularly 
for the last twelve months." " Well ; if she has 
pains like those of labour, attended with a discharge 
of coagula, I have little doubt but she is miscarry- 
ing." The gentleman was rather irritated at this 
opinion. I accompanied him, however, to his house, 
and on entering the bed-room was shown a close- 
stool pan nearly full of coagulated blood ; I plunged 
my hand to the bottom of the vessel ; and after a 
short search, fished up a little foetus about the size 
of my fore-finger. Always, therefore, bear it in your 
mind, that monorrhagia may be the consequence 
either of commencing abortion, of polypus uteri, or 
of a cancerous state of the uterus. 



(f ) LEUCORRH03A, OR FLUOR ALBUS. 



Women are very liable to a puriform discharge 
from the vagina, which varies in colour in different 
cases, being sometimes green, yellow, or white ; most 
frequently of the latter appearance : therefore the 
disease is vulgarly termed the whites. Sometimes 
it is merely a local complaint of no great consequence, 
unattended with pain, or with any constitutional de- 



LEUCORRHCEA, ETC. 41 

rangement ; but at other times it is complicated, with 
much constitutional disturbance ; such as disorders 
of the stomach and bowels, lowness of spirits, and 
general debility; there is a pale, leucophlegmatic 
countenance, with a dark circle around the eyes. 

We know very little more of the source of the dis- 
charge than that it flows from the external orifice of 
the vagina ; but whether it is secreted by the mem- 
brane lining that canal, or by that lining the cavity of 
the uterus, it is difficult to determine. It often oc- 
curs during pregnancy : it must then flow from the 
membrane lining the vagina, as the os uteri is at 
that time hermetically sealed. Women have died 
when labouring under this disease, and the inside 
of the uterus has been found covered with this secre- 
tion ; in such instances it must have proceeded from 
those vessels which pour out the menstrual fluid. 
We are well aware of the sympathy which subsists 
between the uterus and the constitution generally; 
but the connection is less intimate between the va- 
gina and the constitution ; therefore, in the severer 
forms of the disease, which are attended by consti- 
tutional derangement, we suppose the discharge to 
proceed from the uterus ; and from the vagina, in 
those more trifling ones, in which the general health 
does not appear to suffer. 

In speaking of some other forms of uterine derange- 
ment, I said that it was difficult to ascertain whether 
they arose from a disordered state of the constitution, 
or whether the constitution was secondarily affected 
by the -disordered function of the uterus. Persons 
who would not permit their hearers to suppose them 
ignorant of the nature of any disease, affirm confi- 
dently that leucorrhcea arises from a disordered state 
of the general health ; but if they would be candid 
enough to state the truth, they would confess them- 
selves unequal to a discrimination of the order of 
the derangement in all cases. In some instances 
the disease certainly does commence in the uterus : 



42 DISEASES OF FEMALE ORGANS OF GENERATION. 

a woman has procidentia uteri ; after the reduction 
of which a pessary is introduced, it occasions irrita- 
tion, and leucorrhoea follows. Here the disease must 
originate from the irritation of the uterus ; but it is 
difficult to determine which is the cause, when both 
the uterus and the general health become disordered 
about the same time. There is, however, much 
reason to believe that the uterus is first affected ; since 
leucorrhoea often succeeds frequent abortions, diffi- 
cult labours, and excess of venery. 

In leucorrhoea there is, accompanying the dis- 
charge, general debility, with considerable disorder 
of the digestive organs. Which of these symptoms 
claims our first attention? The treatment should, 
from the commencement, be appropriate to them all. 
The derangement of the digestive organs will require 
the use of such gentle laxatives as will produce two 
evacuations daily ; these may be given in conjunction 
with tonics, such as bark, steel, acids, together with 
the use of the cold bath ; at the same time the diet 
should be light, nutritious, and suited to the digestive 
powers. Some persons begin with a drastic purge ; 
and others with an emetic, and after that an aperient ; 
and depend, for diminishing the unhealthy secretion, 
upon a long list of astringents : green tea, which can 
always be procured readily, and excites no suspicion, 
is efficacious as any of them. Half a drachm of the 
sulphate of zinc, dissolved in six ounces of rose water, 
forms a good injection; some of which may be thrown 
up the vagina with a syringe twice or three times a 
day. But it is to be remembered that the best lotion 
will lose its effects in a week ; have then a half dozen ; 
and when one fails, use another for a week, until you 
have tried, them all, and then employ them again. 
The treatment of leucorrhoea is to a great extent em- 
pirical. Cold astringents, among the rational practi- 
tioners, are in the most general use ; but tepid ones 
are often equally beneficial. Practitioners have ex- 
hausted all the cold astringent remedies, and then, 



frj* 



LEUCORRHCEA, ETC. 43 

having recourse to tepid ones, the patient has been 
cured immediately. The liquor plumbi subacet. 
dilut. is now used at the Middlesex Hospital, tepid, 
and with general success. The strength of this ap- 
plication is to be gradually increased until it is 
doubled. It is in this complaint as in ophthalmia, 
that you cannot tell a priori whether mid or tepid 
applications will be the most successfu/pTf therefore 
one fails, the other should be tried. The sexual, are 
intimately connected with the urinary organs, which 
appears to have suggested for the cure of leucorrhcea 
such remedies as the turpentines and the tincture of 
cantharides : the latter may be given in doses of ten 
drops, three times a day, increased two drops at each 
dose up to twenty, or even thirty drops, or until slight 
symptoms of strangury are produced ; when the dose 
is to be reduced to such as may be borne without this 
effect. Many cases of the most obstinate leucorrhcea 
have been cured by this remedy. The balsam co- 
paibge, from the celerity with which it cures go- 
norrhoea, after the inflammatory stage has subsided, 
has been suggested, by analogy , for the cure of leu- 
corrhcea, and has frequently been prescribed with 
success. The best form of its exhibition is on sugar, 
to the amount of half a drachm, together with a little of 
the tincture of lavender. Leucorrhcea is very common 
in married women, scarcely one in ten of those re- 
siding in London being entirely exempt from it ; but 
in girls it is comparatively rare. Dr. William Hunter 
states that in Italy it is imputed to insufficient cloth- 
ing : he was therefore in the habit of directing fe- 
males, suffering under this complaint, to wear good 
substantial flannel breeches. i 





, ^jutt^'a. <**nri*-VtljGy m *~*i0 ?~^ 



yfaZZl*- t**^~ -i>£c fUPVa. 



fL^rf ■*-"'- ^~^ ^CZ&>UC Cv*rfSt»'*H-j &TK4L 



44 DISEASES OF FEMALE ORGANS OF GENERATION. 



(g) FINAL CESSATION OF THE MENSES. 

At the age of forty-five women expect the menses 
to cease, and they call this period the dodging time. 
This evacuation does not cease suddenly, but be- 
comes irregular ; at first not returning for two or 
three months, then profusely, and not appearing again 
for perhaps a still longer period ; it may then recur, 
and continue profusely for a week or two, and then 
its return may be so frequent as once in a fortnight. 
At length the intervals of its recurrence are still 
more distant, until about the age of forty-eight or 
fifty, when it ceases entirely. Women are very 
anxious about this period, which they term empha- 
tically the turn of life ; and they have reason for 
their anxiety. At this time disease of structure is 
the most likely to occur, such as cancer of the uterus 
or breast ; and the health is in general more or less 
disordered. 

During the menstrual period the constitution had 
to form sufficient blood for its own support, as well 
as a superfluous quantity of this fluid for the purposes 
of menstruation : if on the final cessation of the men- 
ses no more blood is formed than is necessary for 
the support of the constitution, this period will be 
passed over with very little disturbance ; but if the 
, blood is formed in the same quantity at this period 
as previously, there will be a superfluity of this fluid 
for which there is no outlet, and there will occur 
congestion ^bout the head, with other, symptoms of 
; , plethora. For "the .relief of these symptom* it may 

be necessary to- taker ploofl from s the arm; but the 
same purpose rnay be, accomplished generally by 
directing a W diet, abltimVnee frdto fermented 
Hqutors, .&^such;aperi€r4s w as will ketone bowels 

l .. . v . v * * * *" » ... 



PRURITUS PUDENDI. 45 

gently relaxed, together with regular exercise. Of 
the diseases of structure connected with this period 
we shall speak hereafter. 



(h) PRURITUS PUDENDI. 



On separating the labia pudendi, a deep groove or 
slit is seen, which is called the vulva. It is lined 
with a mucous membrane, which is sometimes the 
seat of incessant itching. This irritation is so intoler- 
able, that the female can seldom desist from rubbing- 
or even scratching violently the part affected. A 
female troubled with this disease cannot go into 
company, but shuts herself up in her bed-room : it 
has been so severe as to have occasioned suicide. 

Take care that you make no mistake between this 
and an herpetic disease, and that you distinguish 
between the itching of pruritus pudendi and that 
occasioned by vermin, called morpiones, or crab-lice. 
Before yon prescribe, you had better ascertain the 
true cause of the symptom, by getting some female 
to examine the parts ; and if there are neither her- 
petic eruptions, nor morpiones, it is a case of pruritus 
pudendi. Pruritus often arises from irritation in 
some other part, as in the rectum, the uterus, or the 
bladder. If the patient has ascarides moving about 
in the rectum, they often excite dreadful itching in 
the vulva. An effectual remedy for this complaint is 
an injection, thrown up the rectum every night, 
consisting of two scruples of aloes rubbed up with 
half a pint of lime water ; this, in conjunction with 
calomel purgatives, will clear the rectum of the asca- 
rides, and cure the pruritus. Pruritus may also be 
occasioned by the presence of an ovum in the uterus. 
Pregnant women are very liable to it, and it will 
sometimes continue till the end of pregnancy. Dr. 

7 



46 DISEASES OF FEMALE ORGANS OF GENERATION. 

Wm. Hunter relates a case in which a woman in 
labour suffered more from the excessive itching occa- 
sioned by this complaint, than from the labour-pains. 
Here it seems to proceed from local nervous irrita- 
tion, together with increased vascular action ; for if 
the parts be inspected, they appear preternaturally 
red. To relieve this turgescence of the vessels, apply 
eight or ten leeches as near the seat of the affection 
as possible, and use lotions either cold or warm as 
may be found on trial the most advantageous. Dip 
a large sponge in warm or cold water, and shower 
down its contents frequently over the parts affected; 
keep the bowels in a lax state with oily, not saline 
purgatives. Recommend abstinence from all spicy 
diet and fermented liquors. Pruritus pudendi may 
also be dependant on an irritable state of the bladder, 
or on calculi producing irritation, which latter, how- 
ever, in females are of rare occurrence. 

If we find that this disease does not arise from any 
of the above causes, the expedient recommended by 
Dr. Wm. Hunter may be tried, which consists in the 
introduction of the female catheter into the urethra, 
which is said to afford considerable relief. Dr. Cul- 
len sent a patient labouring under this complaint to 
Dr. Hunter, requesting him to introduce a catheter, 
and to allow it to remain in some days; which cured 
her. The disease returned, and the same remedy 
was again equally successful. He tried it after- 
wards on other patients, and found it to succeed ; 
therefore, if other measures fail, introduce the catheter 
into the bladder, and keep it there two hours in the 
twenty-four, for some days. Should this plan not 
succeed, you must diminish the sensibility of the 
parts ; and if that fails, increase it, which will pro- 
duce a new action, by which, if continued for some 
time, the morbid irritability of the parts will be su- 
perseded : should, however, these means prove inef- 
fectual, you must have recourse to counter-irritation. 

7 J 

To diminish the sensibility of the parts, use narco- 



FUROR UTERINUS. 47 

tics; such as infusion of tobacco unguent, cicutse, 
made by mixing the juice of the plant with lard ; or 
use an ointment with opium in it, to be applied liber- 
all y, so as to keep the part affected constantly under 
its influence. As a stimulating application, the parts 
may be washed frequently with a lotion composed 
of two grains of the hydrarg. oxymur. dissolved in 
an ounce of lime water : this is a good remedy. If 
the parts have been abraded by violent scratching 
or rubbing, these excoriations should be first healed. 
In the cases of two old women, who were afflicted 
with this disease, for the cure of whrch all other 
remedies had failed, an issue was made in. the upper 
part of each thigh; these discharged copiously, and 
by this mode of counter-irritation the complaint was 
cured. The disease often resists every remedy which 
has been suggested. By some it is mistaken for 
furor uterinus ; but in pruritus pudendi there is only 
a most intolerable itching, without any increase of 
venereal appetite. 



(i) FUROR UTERINUS. 



In this disease women are troubled with an inor- 
dinate desire for venery. Country girls, being more 
chaste, are not so liable to this complaint as those 
living in town. In males the frequent excitement 
of the sexual organs by onanism disposes to noctur- 
nal emissions of semen, which produce a very irrita- 
ble and debilitated state of the whole system. Wo- 
men have no semen ; yet, during coition, there is an 
effusion cf fluid from somewhere, and trifling causes 
will excite its ejection. The frequent emission of 
this fluid will occasion the same disordered and de- 
bilitated state of health in the female as is produced 
bv onanism and its consequences in the male. I 



48 DISEASES OF FEMALE ORGANS OF GENERATION. 

was consulted by a lady, who had several children, 
who was labouring under great debility both of body 
and mind. She disclosed her secret to me, and said 
she had the most irresistible disposition to lascivious- 
ness imaginable ; that when alone she could not 
desist from rubbing the parts until she became ex- 
hausted and bathed in perspiration ; she slept well, 
but as soon as she was awake the same propensity 
recurred. Another lady who consulted me, said 
she had always been brought up virtuously, and had 
hitherto been well disposed ; but now a man could 
not pass without her experiencing those sensations 
which were alone her husband's right. Here we 
must soothe the sexual irritation, and restore the 
general health by bark, acids, light nutritive diet, 
and by cold bathing. Spices and fermented liquors 
must be totally prohibited. Camphor taken inter- 
nally, and cold applications to the parts affected, are 
beneficial in this complaint. I prescribe camphor 
as follows : — A scruple of camphor to be rubbed up 
with mucilage in four ounces of water, and a third 
part to be given three times a day, gradually increas- 
ing the camphor until one drachm is taken daily. 
Apply cold water, or vinegar and water, to the peri- 
na3um, and throw into the rectum cold water injec- 
tions as recommended in monorrhagia. Warm appli- 
cations in some cases might be more soothing, and 
may be tried if the others fail. Send your patients 
into the country, or to the sea-side, where they may 
have the advantage of cold bathing. 



(k) IMPERFORATE HYMEN. 



The orifice of the vagina is naturally, though not 
completely, closed by a membrane called the hymen, 
which has an opening through it, varying in shape 






IMPERFORATE HYMEN. 49 

in different females ; it is generally semilunar, and 
is situated at the upper and fore part of the mem- 
brane. This membrane is ruptured at the first sex- 
ual connection, and contracts into two or three folds, 
named carunculse myrtiformes. This membrane is 
sometimes quite imperforate. This is a congenital 
defect, and remains undiscovered by the patient, or 
by her mother, till the period of menstruation arrives. 
The girl then experiences the common symptoms of 
menstruation for two or three days, but no discharge 
appears ; they again occur periodically. The men- 
strual fluid is prepared by the uterus, and several, 
ounces being added each month to the former quan- 
tity, the vagina and uterus are thus by degrees com- 
pletely filled. Inconvenience and pain from disten- 
tion are now experienced, and there is a constant 
state of indisposition in place of the periodical one; 
the disorder is, however, increased at each succeed- 
ing monthly period. At length, by the accumulation 
of menstrual fluid, the uterus is greatly distended, 
the abdomen enlarged and tense ; and the innocent 
girl, from her increase of size, together with the ab- 
sence of menstruation, may be supposed to be preg- 
nant. Dr. Mackenzie was consulted in the case of 
a young woman labouring under retention of urine ; 
on making an examination per vaginam, he thought 
he discovered the membranes distended by the liquor 
amnii ; and as the patient had full breasts and tumid 
abdomen, with pains going off and returning, he 
considered her in labour. After the lapse of a few 
hours, finding all the symptoms precisely the same, 
be examined more minutely, and perceiving that he 
could not pass his finger up by the side of the tu- 
mour, he discovered that there was an imperforate 
hymen, greatly distended by the accumulation of 
the menstrual fluid. 

After a girl, having all the characters of her sex, 
has arrived at the age of puberty, if she experiences 
•every month the usual symptoms of menstruation, 






50 DISEASES OF FEMALE ORGANS OF GENERATION. 

while no discharge appears, it may be suspected to 
be a case of imperforate hymen. Under this sus- 
picion, an examination should be made before medi- 
cal treatment is directed, which, if the suspicion is 
well founded, must of course be useless. 

Supposing an imperforate state of the hymen to 
be ascertained, you must divide the membrane by 
means of a lancet carried upwards and backwards, 
and then from side to side, making that which is 
termed a crucial incision, when the retained men- 
strual fluid will gush out sometimes to the amount 
of several quarts, resembling treacle in appearance, 
but not particularly offensive, although so long con- 
fined in the vagina and cavity of the uterus. The 
vagina and uterus must then be cleansed by means 
of a syringe and warm water. Relief being thus 
given, the previous symptoms usually subside ; but 
should any treatment be required, you must proceed 
as may be indicated upon general principles. Peri- 
toneal inflammation has been occasioned by the 
accumulation of the menstrual fluid, which, distend- 
ing the uterus, has made its way through the Fallo- 
pian tubes. 

Cases sometimes occur in which the aperture in 
the hymen is properly formed, but the surrounding 
membrane, being of a tough and ligamentous structure, 
will not yield to any efforts of sexual intercourse. 
In cases of this description the attention of the patient 
is not likely to be directed to such circumstance 
until marriage takes place, when this state of 
things becomes the source of great distress both to 
the wife and her husband, giving rise* to much per- 
plexity as to the nature of the impediment. If con- 
sulted on such an occasion, we must insist on obste- 
trical evidence. On making an examination per 
vaginam you will immediately discover the resisting 
membrane. Having thus ascertained the impedi- 
ment, you must proceed to remove it by dividing the 
thickened membrane in the manner before directed, 



MALFORMED VAGINA. 51 



and the reunion of the divided parts is to be pre- 
vented by plugs of lint. 



(1) MALFORMED VAGINA. 

The hymen may be perfectly natural, but the 
vagina behind it, though of its proper length, is some- 
times so small, as scarcely to admit a goose-quill. 
The consequences of this contraction are similar to 
those of the unyielding hymen. In this dilemma a 
medical man is consulted. Inflammation has per- 
haps been produced in the vagina by the effort 
to overcome the obstruction ; there is a burning 
sensation in the vagina, accompanied with dis- 
charge, and the bride and her relatives think that 
the husband has communicated to her some disease. 
On examination, it is found that the contracted por- 
tion of the vagina will not admit the finger. The 
mode of cure is the same as in cases of stricture of 
the urethra ; that is, the vagina must be dilated by 
means of bougies and sponge tents — the former are 
the best. Introduce a bougie previously oiled, which 
passes with some difficulty. Do this at bed-time, and 
the next morning inquire if it produces pain ; if not, 
let it remain twenty-four hours, which I always wish 
it to do. If it occasions much pain you must remove 
it, and introduce a smaller one. At the end of 
twenty-four hours withdraw the first bougie and 
pass up a second, of a larger size ; and thus proceed 
until the vagina will admit a bougie as large as the 
penis. Before the bougies are introduced, you must 
reduce the inflammation which may have been pre- 
viously excited. You must prescribe oleaginous 
purgatives, warm injections, low diet, and forbid the 
use of spices and fermented liquors. 

The vagina may be sufficiently large, yet it may 
be unnaturally short. It is generally of such length 



52 DISEASES OF FEMALE ORGANS OF GENERATION. 

that you cannot feel the os tincse, if you have a short 
finger : but it may be so deficient in this respect as 
to allow the introduction of the first joint only of 
your finger, and consequently it will admit no more 
than the glans penis. For this malformation there 
is no remedy, and the female who is the subject of it 
must be an unhappy companion for life. I once met 
with a case of this kind. Dr. Hunter was consulted 
by a lady in a mask, who had a short vagina. He 
told her she was the most unfortunate wife a man 
could have, there being no cure for her. 



(m) LACERATED PERINEUM. SLOUGHING OF THE SOFT 

PARTS, ETC. 

The perinseum is sometimes lacerated during 
Labour. The head of the child descends first down- 
wards and backwards ; but when it has arrived at the 
hollow of the sacrum, it can go no further in this di- 
rection, as the termination of the sacrum is curved a 
little forwards and upwards, forming the os coccygis ; 
it is, therefore, thrown forwards. As soon as the 
head has passed the sacrum and coccyx, the pressure 
of the child is then thrown wholly upon the peri- 
nseum ; and unless some assistance be rendered, this 
part, together with tfie sphincter ani, will very pro- 
bably be lacerated, and the rectum and vagina be 
made into one canal. The woman then becomes in- 
capable of retaining her faeces, which pass away in- 
voluntarily. The perinseum should be supported 
with the palm of the hand at the time when the head 
of the child is pressing on it, by which the superin- 
cumbent weight of the perinseum is diminished, and 
the head, instead of descending downwards and back- 
wards, is made to descend downwards and forwards. 
I have met with this accident only once, and that 
not in a natural labour, but during the application 



LACERATED PERINEUM, ETC. 53 

of the forceps, when it is not an uncommon occur- 
rence. 

The forceps being properly applied, if the head is 
situated high up, we first pull downwards and back- 
wards; and as soon as the perinseum is distended, 
we apply one hand to support it, and continue the 
extraction with a diminished force downwards and 
forwards. But by continuing to pull downwards 
and backwards, not giving at the same time suffi- 
cient support to the perinaeum, laceration takes place. 
If the laceration is recent, and does not extend into 
the rectum, it readily closes. The parts are to be 
washed with warm milk and water three times a day ; 
the patient should lie constantly on her side, and her 
knees are to be kept in close contact. In nine cases 
out of ten the laceration does not extend through the 
sphincter ani ; this you can ascertain by passing your 
finger from the vagina to the rectum in the course 
of the perinseam.* 

If the sphincter ani be lacerated, and the rectum 
and vagina made into one canal, this state may con- 
tinue for months, or even through life. On visiting 
a lady about three months before her confinement, I 
asked if her health was good ; she said yes, except a 
chronic diarrhoea, which prevented her going into 
company; for as soon as she felt a disposition to 
evacuate the bowels, their contents came away. She 
had been attended by several physicians, none of 
whom had examined her, but prescribed hydrarg. 
cum creta, astringents, &c. I did not examine the 
parts until the period of actual labour ; when I soon 
discovered a laceration of the perinasum and sphinc- 
ter ani. I met with another female, who had been 

* To these directions it may be added, that a diffused immetho- 
dical support of the perinseufn during delivery by the forceps is 
frequently ineffectual ; this support should extend to that precise 
point of the perinaeum at which the labia unite, where the 
strain is the most considerable, and from whence the laceration 
commences. 

8 



54 DISEASES OF FEMALE ORGANS OF GENERATION. 

treated for chronic diarrhoea, labouring under a simi- 
lar misfortune. I do not know why we may not 
operate here' as for the hare-lip, by paring off the 
edges of the parts, and keeping them in contact, 
with a view to their union. I have now two pa- 
tients using an instrument devised to palliate this 
malady, which they say is very effectual. They 
can now visit, or receive company : the instrument 
is a circular band of steel, which goes round the 
body just above the hips ; from behind, a piece of 
steel, somewhat elastic, and so fixed as to admit of 
its being moved to either side, descends, and incur- 
vates forwards between the nates, and then turns a 
little upwards. At the end of this piece of steel is 
an ivory ball, on which is placed a sponge suffi- 
ciently large to cover the vulva, perinseum, and 
anus : when the patients evacuate the bowels, they 
have only to turn it on one side. 

In some cases of very protracted labour, when the 
head of the child presses on all sides, inflammation 
and sloughing ensue ; the labia, vagina, and sur- 
rounding soft parts, are destroyed to such an extent, 
that, on the separation of the sloughs, an opening is 
left, communicating with the bladder in front and 
the rectum behind. Thus the vagina becomes a 
receptacle and passage for both urine and faeces. As 
the bowels in health are seldom open more than once 
in twenty -four hours, the posterior part of the wound, 
being undisturbed for long intervals, will sometimes 
gradually contract, and at last close. But not so the 
communication with the bladder. The water is 
constantly dribbling away, and the aperture becomes 
fistulous. Mr. G. Young suggested to me a mode 
of treatment in cases of this kind, by the introduc- 
tion into the vagina of an Indian rubber bottle with 
a piece of sponge sewed to it. This sponge should 
be placed opposite to the fistulous opening in the 
bladder. The urine absorbed by it may be occa- 
sionally pressed out with the finger : a fresh bottle 



POLYPUS UTERI. 55 

should be introduced every morning, and the bladder 
should be emptied by the catheter several times 
every day. Mr. Barnes, of Exeter, had two* of 
these cases under his care ; he wrote to ask my ad- 
vice, and I mentioned this plan to him, which he 
tried, drawing off the patient's urine three or four 
times a day with a catheter. In two months, on mak- 
ing an examination of the parts, he found the fistu- 
lous communication much smaller. He replaced 
the bottle in the same manner ; and in a few months 
the opening was completely closed. It is not neces- 
sary that the surgeon should attend daily to draw 
off the patient's urine. Teach a patient or a nurse 
the anatomy of the parts, and let either of them in- 
troduce the catheter. This complaint is a most dis- 
tressing one, and demands on the part of the medi- 
cal practitioner the greatest attention, and the careful 
employment of any remedy which promises to be 
effectual. 



(n) POLYPUS UTERI. 



Menorrhagia arises from functional derangement 
of the uterus. Haemorrhage, or flooding, may, how- 
ever, ensue from an alteration of the structure of the 
uterus ; and it is an important rule, in obstinate and 
long standing cases of haemorrhage from this organ, 
which have resisted the usual remedies, to examine 
the state of the parts per vaginam, by which alone 
the cause of the symptoms may be discovered, and 
an appropriate treatment adopted. Some profuse 
discharges from the uterus are the precursors of 
abortion ; some arise from scirrhus producing vari- 

* More than two cases are alluded to in the paper of Mr. Barnes 
on this subject, read by Dr. Gooch to the Medical and Chirurgical 
Society. See Med. and Chitttrg. Transactions, vol. vi. p. 583. 



56 DISEASES OF FEMALE ORGANS OF GENERATION. 

ous kinds of altered structure ; others from polypi 
growing from the cavity of the uterus. 

When a discharge suddenly comes on, attended 
with throes recurring every few minutes, I consider 
it as the commencement of abortion. But when the 
discharge has continued for weeks, producing those 
affections of the brain which arises from too scanty 
a supply of blood, as nervous headache, singing in the 
ears, susceptible state of the mind; and, connected 
with disorder of the digestive organs, a pasty, leu- 
cophlegmatic countenance, and lancinating pains 
deeply situated in the region of the uterus, I con- 
clude that there is scirrhus, or cancer, in some or 
other modification. When the above-mentioned 
symptoms are unattended with lancinating or burn- 
ing pains in the uterus, have resisted all remedies, 
and are accompanied with a sense of weight or 
burden in the part, I conjecture the case to be one 
of polypus uteri. If this conjecture is confirmed on 
examination, instead of finding an empty vagina, 
you discover in it a tumour varying in size in differ- 
ent cases; ii may be that of a walnut, an apple, or 
a child's head. These tumours grow from different 
parts of the uterus — the fundus, the cervix, or from 
the edge of the os tineas — when from the two last 
situations they are always easily detected, as they 
must immediately descend into the vagina; but 
when the tumour grows from the fundus uteri, and 
is of moderate size, it still remains in the cavity of 
the uterus, and you cannot, by an examination per 
vaginam, readily discover it. At length it grows 
larger, and the uterus, as in its gravid state, enlarges 
with it: it then excites the muscular fibres of the 
uterus, when it is suddenly expelled through the os 
tineas into the vagina, where it is easily recognised. 
As the size of the tumour increases it occasions 
much uneasiness ; it presses forwards on the urethra, 
producing retention of urine, and backwards on the 
rectum, occasioning a difficulty in passing the fasces. 



POLYPUS UTERI. 57 

The patient feels a weight in the vagina, and a sen- 
sation as if something was about to come away. If 
it is neglected, and if the discharge does not kill the 
patient, the tumour at last presents itself between 
the labia externally. A case of this kind occurred ; 
and on its being discovered, the tumour, which had 
a slender neck, was cut away with a pair of scissors. 
The patient was in so weak a state that the operator 
thought she would have died in a few hours. The 
haemorrhage, however, ceased immediately, as it 
usually does, as soon as the tumour is removed; her 
constitution rallied, and she did well. In these cases 
medicine is of no use. The injections of cold water 
into the rectum are, for a time, palliative. Tonics 
and nutritive diet may for a while support the 
strength ; but the patient will decline and die, un- 
less the tumour is discovered, and a cure accom- 
plished by its removal. This may sometimes be 
effected with impunity by means of the knife or 
scissors ; but this method may be followed by a fatal 
haemorrhage. All practitioners now use the liga- 
ture, which is passed round the neck of the tumour, 
and drawn so firmly as to prevent the circulation 
through it ; this ligature is tightened daily until the 
tumour drops off. 

There is often much difficulty experienced in ap- 
plying and tightening the ligature with the old in- 
strument ; this led me to think of the construction 
of another. It consists of two straight silver ca- 
nulse, about eight inches in length ; a strong ligature, 
as of whipcord, is to be passed through one of these 
canulae, and from this, through the other; the ends 
of the ligature will hang from those of the canulae, 
which are connected above by the passage of the 
ligature from one to the other. These canulae are 
to be placed close together, so as to form as it were 
only one instrument, and are then to be introduced 
in front of the tumour as high as the place where it 
is intended to tie it ; the canulae are then to be 



58 DISEASES OF FEMALE ORGANS OF GENERATION. 

separated ; one of them is to be carried round the 
tumour in one direction, and the other in the oppo- 
site direction, when they again meet, and are to be 
kept close together. Thus the ligature is passed 
round the base of the tumour. It remains to fix 
these canulse ; and this is done by an instrument 
consisting of a small silver rod, having two rings at 
its upper extremity, just large enough to admit the 
two canulse, (these rings are joined together at their 
sides,) and two short canulse, forming one double 
canula at its lower extremity, with rings at their 
sides, to which the ligature is to be fastened. The 
ligature being passed round the neck or base of the 
tumour, and the canulse being held close together, 
the rings of the instrument just described are to be 
passed over the canulaB to their upper extremity, 
by which at this point the canula? will be held 
close together : the short canulse are in like manner 
to be passed over the lower extremities of the long 
canulse, which also will be kept by them close to- 
gether. Thus the canulse are so fixed, both above 
and below, as to form only one instrument. The 
ends of the ligature are now to be drawn tight, and 
are then to be fastened to the little rings projecting 
from the sides of the short canulae.* 

Having completed the operation of tying the neck 
of the polypus, and given the patient the necessary 
directions, it will be proper that you see her every 
day, when you have two important objects of atten- 
tion : the first, to cleanse the vagina and uterus of 
the fetid discharge consequent on the death of the 
tumour ; the second, to tighten the ligature every 
day until the tumour comes away. The tumour for 
the first twenty-four hours swells, but afterwards it 
becomes flaccid and discharges a fetid matter, 
which, if allowed to accumulate, might cause irrita- 

* For a plate of this instrument, see Dr. Gooch's work " On 
some of the Diseases incident to the Puerperal State." 



POLYPUS UTERI. 59 

tion, headache, and fever. This discharge you wash 
away by injections of tepid water, by means of an 
elastic catheter introduced into the uterus. The 
apparatus may be thus made : — Fix a cork, with a 
hole through it, on the pipe of a syringe ; let the 
orifice in the cork, through which the catheter is to 
be inserted, be of such a size that the catheter may 
be firmly fixed into it ; through this catheter you 
may inject into the uterus half a pint of tepid water, 
by which the discharge will be washed away, and 
any unpleasant symptoms prevented from its absorp- 
tion. If the discharge is very profuse and very 
offensive, the injections of warm water should be 
used twice a day. The ligature generally cuts 
through the tumour in six or eight days, and the 
polypus comes away. Sometimes the tumour is so 
large, that the aid of the midwifery forceps is re- 
quired for its extraction. The haemorrhage, which 
has continued for many months or years, ceases on 
the removal of the tumour; the functions of the body 
are gradually restored ; and the woman, who just 
before had a pallid countenance, soon has a rosy 
cheek. After the operation, attention to the state of 
the bowels is necessary. In some cases tonics are 
required, of which acids are perhaps the best. 

The hemorrhage attendant on polypi of the uterus 
is constant, but is aggravated at the menstrual pe- 
riod. I have succeeded in curing many cases of this 
disease which had baffled the skill of eminent prac- 
titioners, who, not having ascertained its nature by 
an examination, had mistaken it for menorrhagia. 
A lady had been suffering from flooding during a 
year and a half. Her cheeks were like those of a 
corpse. She had headache, singing in the ears, and 
her body was much emaciated. The day before I 
saw her she had taken a purgative, which had pro- 
duced retention of urine — the straining at stool had 
forced the tumour against the urethra. Many able 
men had attended her. I looked at their prescriptions, 



60 DISEASES OF FEMALE ORGANS OF GENERATION. 

and perceived they had employed all the "usual re- 
medies for menorrhagia. As the discharge had con- 
tinued so long, I suspected the existence of a poly- 
pus, and refused to prescribe without examining the 
state of the parts, when my suspicion was confirmed. 
The next day I applied the ligature, tightening it 
daily, and cleansing the parts of the discharge ; on 
the ninth day the polypus came away ; from that 
time she had no return of the haemorrhage, and has 
since menstruated regularly. No medicines were 
administered, except pro forma. I took care of the 
uterus, and left the constitution to take care of itself. 
She recovered with amazing rapidity. 

The neck or stalk of the polypus is sometimes so 
small that, by slightly pulling it, the tumour comes 
away, and no haemorrhage ensues. When a ligature 
is applied to the neck of a polypus, which is itself 
insensible, the only pain occasioned by it is a slight 
sense of dragging ; but if a portion of the uterus be 
included, the most violent pain will be produced. 
Dr. Denman once applied a ligature to a polypus 
uteri : he tightened it, and immediately the patient 
complained of pain; he relaxed the ligature, and 
again pulled it, and with the same effect. Being a 
cautious man he loosened the ligature, and left it in 
the uterus ; she died in a day or two. On examin- 
ing the body, he found the polypus had grown from 
the fundus uteri, and by its weight had partly in- 
verted the uterus, around which he had placed the 
ligature. Dr. Hunter in a case of this kind applied 
a ligature, and drew it tight ; violent pain was pro- 
duced ; he slackened it, the pain ceased ; he pulled 
it again, and agonizing pain was occasioned ; he told 
the patient she must bear it ; he gave her an opiate, 
and thus left her. The next day he found her with 
a thready and almost imperceptible pulse, bathed in 
cold sweats, with a cadaverous, Hippocratic counte- 
nance. She soon died ; and he discovered on exami- 



POLYPUS UTERI. 61 

nation, that he had included a portion of the uterus 
in the ligature. 

Never tighten the ligature when it produces the pain 
which it would occasion on a part possessing sensi- 
bility ; rather let the ligature be removed and applied 
lower down, where the tightening of it is not produc- 
tive of pain. It is not necessary to tie the polypus 
at the top of its neck ; it is quite sufficient to tie it 
where it projects from the uterus into the vagina, 
supposing such to be the situation of it. The stalk 
will not grow again, but will gradually diminish, and 
leave no vestige behind. All these cases are unac- 
companied with diseased structure of the uterus. 
But there are some cases of fungus having a broad 
base, and apparently of a malignant nature, in which 
the uterus itself is diseased. In such cases the liga- 
ture is of no use, as the fungus, if removed, would 
grow again, and the fate of the patient would be 
accelerated by its employment. When the uterus 
itself is diseased, in addition to discharges from this 
organ, and disorder of the general health, there is 
most commonly more or less of pain, perhaps of a 
lancinating kind, and the region of the uterus is also 
tender on pressure. In such cases the treatment 
must be directed chiefly to the preservation or im- 
provement of the general health, together with the 
use of such palliatives as the symptoms may require. 
Malignant fungi of the uterus are rare : those of a 
benign character are the most frequent. 



9 



62 DISEASES OF FEMALE ORGANS OF GENERATION. 



(o) PROCIDENTIA UTERI. 



This is the displacement of the uterus in its 
healthy state from its natural situation ; and when 
we consider how slightly it is connected with other 
parts, it may excite some degree of surprise that the 
displacement does not more frequently occur. It 
will require a long finger to reach the cervix when 
the uterus is in its natural situation. It is placed at 
the upper part of the pelvis, with its neck resting 
over the cavity of the vagina. The descent of the 
uterus into the vagina is the most frequent among 
females who stand much in the erect posture : and 
it would occur more frequently, if it were not, in 
the first place, that the uterus is small and light ; in 
the second, that it is supported by its proper liga- 
ments ; in the third, that the vagina, on which it 
rests, is small. So long, therefore, as the relations 
of these parts to each other are natural, the uterus 
will remain in its proper position ; but if the vagina 
becomes wider, and the uterus heavier than natural, 
then the latter begins to sink into the cavity of the 
former. This is the state of the parts after parturi- 
tion. The uterus is then preternaturally large and 
heavy : and having lately contained the foetus and 
its appendages, some time must elapse before it is 
contracted to its original size. The vagina also is 
at this time much wider than is natural ; and, having 
recently admitted the passage of a child through it, 
this part also will require some days to resume its 
natural capacity. Sitting up prematurely in the 
erect position after delivery very much disposes the 
uterus to this accident ; and, in some patients, even 
when in the horizontal position, a trifling exertion, 



PROCIDENTIA UTERI. 63 

such as straining at stool, &c, will be sufficient to 
occasion procidentia uteri. I believe that nineteen 
cases in twenty arise from sitting up too soon after 
delivery. It is, however, by no means invariably 
connected with parturition ; on the contrary, it ap- 
pears sometimes to occur from mere relaxation of 
the parts, as in some emaciated subjects, without any 
obvious deviation from their natural size or struc- 
ture. 

The uterus descends into the vagina in different 
degrees. It may descend a little way, and require 
the introduction of half the length of the finger to 
detect it ; or it may descend so low, that the cervix 
uteri protrudes through the external orifice of the 
vagina. The procidentia is called imperfect or in- 
complete, when the uterus is still within the cavity 
of the vagina; but when it descends so low as to 
appear externally, this state is designated as the 
perfect or complete procidentia uteri. You must 
never forget that the uterus may be displaced 
without appearing externally : it is, however, then 
only that the women recognise the displacement. 
Many cases of imperfect procidentia have been mis- 
taken for those merely of constitutional derangement. 
The stomach is sympathetically affected by the state 
of the uterus, and nervous affections and debility 
ensue, which have been treated with tonics, &c. ; 
but when procidentia has been ascertained, if the 
uterus is properly managed, the constitution will 
take care of itself, and these symptoms will speedily 
disappear. How are we to discover the existence of 
this complaint? When the uterus protrudes exter- 
nally between the labia, the patient herself will tell 
you that she has a falling down of the womb. If it 
is an imperfect procidentia, we suspect it from the 
pain which the patient experiences at the sides of 
the sacrum, from a sense of painful dragging in the 
region of the uterus, and of fulness and pressure in 
the vagina, as if something was about to come away. 



64 DISEASES OF FEMALE ORGANS OF GENERATION. 

If the patient assumes the horizontal position, these 
symptoms subside altogether, or are gradually re- 
lieved. The uterus presses both behind and before, 
occasioning a difficulty in passing both urine and 
fseces. These are the local symptoms. The con- 
stitutional symptoms are — a disordered state of the 
stomach and of the whole system, accompanied* with 
a train of nervous sensations. It is here necessary 
to examine the patient per vaginam, but let me give 
you a caution, to which, if you do not attend, you 
may overlook the existence of the malady. We can 
examine patients in humble life as we please, but 
those in higher stations require a little more cere- 
mony. You must not direct your patient to continue 
in bed in the morning, and say that you will call 
and make an examination. If you do this, the uterus, 
after the patient has been in the horizontal posture 
all night, will, most probably, like a hernia, have 
returned to its natural situation ; and not being able 
to feel it, you will pronounce that there is no proci- 
dentia. The procidentia is a mere hernia of the 
uterus. Rather direct your patient to empty the 
bladder and rectum; to get up, and to walk about 
for two or three hours, and examine her in an upright 
position. The uterus cannot then return ; it must 
still be displaced. Always take care to have the 
bladder and rectum emptied previously to an exami- 
nation, and examine in that posture in which the 
complaint is aggravated, as it is in the erect position. 
If the patient must remain in bed, prop her up well 
with pillows ; but you may direct her to sit on the 
edge of a sofa, in which situation the examination 
may be made without any indelicacy ; and you will 
not fail to discover the descended cervix uteri. 

What are we to do in these cases ? If the disease 
has been of long standing, there is but little expecta- 
tion, from professional aid, of a radical cure. By 
prudent management after a delivery the occurrence 
of this complaint is easily prevented ; or if it had ex- 



PROCIDENTIA UTERI. 65 

isted at a former period, this opportunity is highly 
favourable, if made the most of, for preventing its re- 
currence. But supposing a treatment to be instituted 
without the advantages afforded by parturition, we 
must, as in hernia, return the displaced parts, and 
keep them up by a kind of trass, which we call a 
pessary. When the procidentia is not complete, the 
uterus readily resumes its natural situation ; but when 
the procidentia is complete, it is often difficult to re- 
turn it through the external orifice of the vagina. 
The best method of proceeding is first to apply the 
cloths saturated in some cold lotion, with which the 
parts are to be kept constantly wet. By the evapo- 
ration of the fluid, such a degree of cold will be pro- 
duced, as will induce a contraction of the uterus in 
a few hours, and permit its return with ease. After 
the uterus has been replaced, we prevent its descent 
by the introduction of a pessary. 

When a disease is incurable, you have three hun- 
dred and sixty-five remedies ; and when the uterus 
thus protrudes, you have three hundred and sixty-five 
instruments to keep it up : but they are imperfect. 
The common pessary is made of box-wood ; it is flat, 
with a circular hole in the middle. You reduce the 
uterus completely, and keep it up with your finger ; 
then the pessary being greased, with its edge fore- 
most, but not transversely, introduce it into the vagina 
gently, but perse veringly, not forwards against the 
pubes, but against the perinseum : when introduced 
into the vagina, elevate the edge which presses on 
the perinseum (by which the pessary will be placed 
transversely in the vagina, from ilium to ilium), until 
its flat surface is fairly turned uppermost towards the 
uterus, and thus you have a platform on which the 
cervix uteri may rest. The pessary should be so 
large as to be admitted with some little difficulty ; 
for if it goes in easily, it will come out easily, and 
will not remain in the vagina. A little difficulty in 
the introduction of it insures the preservation of its 



66 DISEASES OF FEMALE ORGANS OF GENERATION. 

place. The pain, however, occasioned by the intro- 
duction of the pessary ought soon to cease. If it con- 
tinues, we conclude that the instrument is so large 
as to press uncomfortably upon the adjacent parts, 
and a smaller one must be substituted. The pessary 
which I have just described is an awkward one, and 
requires the surgeon to be constantly in attendance ; 
for when the patient walks it is likely to slip, and the 
edge becomes tilted up. It is better to use one which 
the patients can introduce themselves. Such a one 
may be made in the following manner : — Take a 
piece of sponge as large and as long as a good sized 
egg, and of the same shape, and to prevent its swell- 
ing and dilating the parts by the absorption of 
moisture, cover it with oiled silk. This forms a soft 
and comfortable pessary. It is introduced with the 
small end of the oval first, and when in the vagina 
turn it, so that the ends shall be from ilium to ilium. 
Some use the globular pessary made of box-wood : it 
is hollow and perforated with holes. If it shifts its 
situation, the same extent of surface is always pre- 
sented for the support of the uterus. This, and the 
sponge pessary, I consider to be the best. As the 
flat circular pessary seemed to press on the urethra 
and rectum, flat oval ones have been recommended. 
When these are used, the mode of introduction is 
similar to that of the circular pessary, and their long 
axes should be from ilium to ilium. There is a 
French invention, which consists of a piece of leather 
stuffed with wool, and varnished. This is rather 
heavy. Pessaries of a similar shape have been made 
by Mr. Savigny of caoutchouc ; they are hollow 
that they may be the lighter. These, as long as they 
are cool, do very well ; but after remaining in the 
•vagina a little while, the air in them becomes rarefied, 
expands, and bursts the pessary with an explosion 
which is not very agreeable to the patient. A lady 
who suffered from procidentia uteri divised a pessary 
for herself, which was thus made : — Melt four ounces 



PROCIDENTIA UTERI. QJ 

of bees- wax, together with a piece of mutton-suet the 
size of a walnut, and pour it into a box of the requi- 
site size, which has a pillar in its centre : turn it out 
when cold, and you have a thin cake with a hole in 
the middle. Thus a pessary is formed, which the 
lady herself has found a very effectual one, and it 
has also afforded relief to many poor women whom 
she has supplied with it. The pessary should be 
taken out every night. The circular hole should not 
be very large, lest the cervix uteri should descend 
into it and become strangulated ; yet it must be so 
large as to admit the passage of the menstrual fluid. 
The globular and the sponge pessaries appear to be 
the best, to either of which some tape may be at- 
tached, which will assist in taking it out. If when 
the box pessaries are used they are not so large as to 
be introduced with some difficulty, they may drop 
out, to the distress of the wearer. 

In chronic cases of procidentia uteri, you must re- 
turn the displaced uterus and apply a pessary, which 
must be regularly worn; in conjunction with this, 
you must endeavour to induce a contraction of the 
vagina by the employment of astringent injections or 
lotions, as one drachm of alum dissolved in half a pint 
of the decoction of pomegranate bark, which may be 
applied three times a day. These cases are seldom 
cured ; but when the complaint is recently discovered, 
that is, within a month or six weeks after its occur- 
rence, a cure may be expected. If pregnancy should 
take place, the uterus, of course, soon after the third 
month ascends spontaneously into the cavity of the 
abdomen; and if the case, as formerly mentioned, is 
well managed after delivery, a cure is probable. Here 
you have two objects of attention : the first, to insure 
the most strict observance of the recumbent posture, 
until the uterus has resumed its natural size and 
weight; and the second, to aid the contraction of the 
vagina by means of the astringent lotion. The best 



68 DISEASES OF FEMALE ORGANS OF GENERATION. 

method of applying it is by a cylindrical piece of 
sponge dipped into it, and introduced into the vagina ; 
it should be constantly worn, and wetted occasion- 
ally ; this method is to be preferred to the use of the 
syringe, as by it the lotion will be applied constantly. 
This plan of treatment is to be continued for three or 
four weeks. The patient may then be allowed to 
assume the erect position for a few minutes, to as- 
certain whether it is productive of pain ; if not, some 
hope of a cure may be entertained. You still, how- 
ever, keep her in the recumbent state for three or 
four weeks longer. Some persons apply cold by 
means of a bidet ; others by cold injections into the 
rectum, by the shower bath, or by cold sea-bathing, 
if convenient. It is very difficult to keep the pa- 
tients, suffering under this complaint, uniformly in 
the recumbent position : if they sit on the sofa with 
their legs up, and the trunk erect, they suppose it to 
be quite sufficient ; but this position is as pernicious 
as standing upright. Let the body be in the hori- 
zontal posture, and we care not where the legs are. 
For the relief of the disorder of the stomach, and of 
the nervous irritation, aperient medicine must be 
given, so as to procure an evacuation from the bowels 
twice a day, together with bitter or acid tonics. The 
imperfect procidentia uteri is often overlooked, and 
the case treated merely as a stomach complaint. 
Two very eminent physicians were consulted by a 
lady; they treated her case as one of disordered, 
stomach ; after a lapse of time, another physician 
was consulted, who, from the uneasy sensations and 
weight experienced about the pelvis, in conjunction 
with other symptoms, concluded that there might be 
an imperfect procidentia uteri. He examined, and 
found it to be so. He returned the uterus, and in- 
troduced the globular pessary, after which the sto- 
mach complaints ceased in about a week. The 
physicians who were first consulted were both men 



CHRONIC INFLAMMATION OF THE UTERUS. 69 

of ability, and of high rank in their profession ; but 
they declared that they never heard of a proci- 
dentia uteri in which this organ did not protrude 
externally. 



(p) CHRONIC INFLAMMATION OF THE UTERUS. 



Acute inflammation of the uterus, unconnected 
with pregnancy, is a rare disease : but its occurrence 
soon after delivery is frequent. Chronic inflamma- 
tion of this organ, in the unimpregnated state, is very 
common. The patient complains of a fixed pain in 
the region of the uterus, aggravated by motion. 
Pressure above the pubes occasions pain. Pain is 
felt also at the extremities of the round ligaments. 
Pain is experienced on touching the cervix uteri in 
an examination per vaginam. With these symptoms 
there is loss of appetite, and a disordered state of the 
alimentary canal. Chronic inflammation of the ute- 
rus frequently succeeds abortion ; for women do not 
attach the same importance to this as to labour at 
the full period of pregnancy, but get up in two or 
three days and walk about. In ten or fourteen days 
after this exertion, they sometimes begin to experi- 
ence the above symptoms. This complaint is also 
sometimes owing to the insufficient clothing of our 
English females ; and sometimes to a disordered 
function of the digestive organs. But it is often 
difficult to trace the disease to its cause : for it is 
allowed to exist week after week, and a month or 
two may, perhaps, elapse before we are consulted. 

In the treatment of this disease the bowels must 
be kept relaxed by so much castor oil as will pro- 
cure two evacuations daily, leeches should be ap- 
plied over the region of the uterus, together perhaps 
with cupping on the sacrum, and alterative doses of 

10 



7U DISEASES OF FEMALE ORGANS OF GENERATION. 

mercury, such as five grains of Plummer's pill, 
should be taken every night ; the patient should also 
use a hip bath, every night for ten minutes, at 94 de- 
grees, and during the day should keep the recum- 
bent posture on a sofa. This plan must be pur- 
sued patiently and perseveringly, as several weeks 
may elapse before any amendment is perceptible. 
After the mercury has been taken two or three 
weeks, it frequently produces a tenderness of the 
gums, and most commonly the symptoms disappear 
as soon as this effect has taken place. I have no 
doubt that dysmenorrhoea is frequently owing to 
chronic inflammation of the uterus. The aching 
pain in the region of the uterus then continues from 
one menstrual period to another, and is aggravated 
during the discharge. From this view of its pa- 
thology the treatment just recommended for chronic 
inflammation of the uterus would be equally proper 
in this form of dysmenorrhoea. 



(q) CANCER UTERI. 



Chronic inflammation of the uterus, if neglected, 
or unskilfully or unsuccessfully treated, may con- 
tinue month after month, year after year, and then 
terminate in scirrhus. When this disease has oc- 
curred, the inflammatory symptoms subside, and 
the tenderness on pressure on the region of the 
uterus, or on the cervix uteri, on an examination per 
vaginam, ceases ; but the situation of the patient is 
not improved : on the contrary, the constitutional 
symptoms and the disorder of the stomach are in- 
creased ; there is a discharge from the vagina re- 
sembling that of leucorrhcea ; the uterus, though not 
painful, is enlarged and heavy ; and the counte- 
nance is leucophlegmatic. All cases of chronic in- 



CANCER UTERI. 71 

flammation of the uterus do not terminate in scirrhns 
deposition, yet we should regard them with a jealous 
eye. In this stage of the disease, what is to be 
done ? The principal object is to prevent or subdue 
inflammatory action, as by the recumbent position, 
by mild purgatives, by a light but nutritious diet, 
by occasional depletion, and by the alterative doses 
of mercury which have been mentioned in the pre- 
ceding section. Sometimes, under this mode of 
treatment, more especially by a slight mercurial ac- 
tion upon the system, the scirrhus deposition disap- 
pears ; and on examination per vaginam, instead of a 
hard, grisly cervix uteri, you will find this part, in a 
few weeks, of its natural softness. Every thick- 
ened and enlarged uterus is not a scirrhus uterus ; 
but we should look on them all with considerable 
suspicion. Scirrhus, or cancerous disease, generally 
commences in the cervix uteri. In some cases the 
disease is indolent, and remains stationary for years, 
while in others the progress is more rapid towards 
cancerous ulceration. We distinguish them as the 
benign and the malignant. In cases of the malig- 
nant character, the inflammatory symptoms recur, 
darting pains are felt, as if needles were piercing the 
part, ulceration takes place, and this state constitutes 
cancer uteri. The leucorrhcea which before existed 
now becomes a fetid discharge — you can even 
smell it when by the bed-side of the patient ; the dis- 
order of the stomach, and constitutional irritation, 
become worse ; the patient passes sleepless nights, 
pain in the pelvic region is constant, with occasion- 
ally lancinating pains ; the countenance has a worse 
expression, and the pulse becomes weak and irritable. 
When you examine per vaginam, the cervix uteri is 
painful to the touch ; and instead of the natural, 
nipple-like projection, its surface is broad, hard, 
ragged, and chapped. The extent of the disease 
may be the more accurately estimated by an exa- 
mination by the rectum, as well as per vaginam. 



72 DISEASES OF FEMALE ORGANS OF GENERATION. 

Dysury is sometimes experienced in the progress of 
the disease. This dreadful disease occurs generally 
between the age of forty -five and fifty years. It is 
irremediable. The ulceration extends in all direc- 
tions ; and as it proceeds, vessels are laid open, and 
haemorrhage takes place ; the patient faints, and 
appears to be almost lifeless ; the fainting stops the 
bleeding, and the constitution rallies, but again to 
sink ; and if the repeated haemorrhage is not fatal, 
the ulceration proceeds backwards into, the rectum, 
and forwards into the bladder, occasioning an invo- 
luntary discharge of their contents into the vagina, 
which is now become a common receptacle for urine, 
faeces, and the fetid discharge from the uterus. I 
have been surprised to see patients live so long in 
this stage of the disease. I find them with their 
eyes half closed, mouth half open, with a corpse-like 
countenance, roused only by pain, which would now 
and then occasion screams or groans : on the subsi- 
dence of the pain they relapse into a comatose state ; 
and I have known them continue in this state for 
ten days. 

With respect to the treatment, this disease admits 
of no cure ; the patient must die, and the only object 
is to alleviate her sufferings, until she is released by 
death. This we are to do by preventing a costive 
state of the bowels, which is a source of irritation to 
the constitution ; by sustaining the system by a light 
nutritious diet, together perhaps with acid tonics ; 
by the use of the warm hip bath,* and by anodynes : 
these latter will consist of the pil. saponis cum opio, 
extr. conii, and extr. hyosciami, given in sufficient 
quantities every night and morning. These will 
allay the pain, but they disorder the stomach and 
impair the appetite. Another resource with a similar 
design is the introduction of anodyne suppositories 

* This remedy may perhaps not be unexceptionable, if there is 
any disposition to haemorrhage. 



CANCER UTERI. 73 

of soap and opium into the rectum. Tepid anodyne 
injections are also recommended, with a view to re- 
lieve local irritation. The vagina should be regu- 
larly cleansed of the fetid and irritating discharge, 
by injections of warm water. Dr. Osiander, of Goet- 
tingen, has in some instances removed the diseased 
portion of uterus. Extirpation is the only remedy 
for cancer of the breast,* and why not have recourse 
to a similar operation here ? but we must consider 
that the uterus is a part situated deeply, and difficult 
to be got at. Dr. Osiander introduces four crooked . 
needles armed with broad ligatures, and passes them 
through the cervix uteri before and behind, and at 
either side. This being done, he pulls at the four 
ligatures, and produces procidentia uteri. He then 
cuts away the cervix, the part most commonly dis- 
eased, with a bistoury or with scissors. The bleeding 
is to be restrained by astringents, or by the introduc- 
tion of a sponge. Dr. Osiander has not been candid 
enough to give us the result of all his cases. A con- 
tinental surgeon, who saw this gentleman extirpate 
a cervix uteri, supposed by the operator to be can- 
cerous, told me that the disease was decidedly not 
of this nature. In this manner the cervix, and as 
much of the body of the uterus as appeared to be 
diseased, has been removed ; it is proper, however, to 
observe, that if the vagina is wounded, and the peri- 
toneum cut through, an opening will be made into 
the cavity of the abdomen through which the intes- 
tines will descend. This operation for the cure of 
cancer has not been performed with success in this 
country. All the efficient treatment of cancer uteri, 
with which I am acquainted, has for its object to 
alleviate the sufferings of the patient. 

* It must be confessed, a very problematical one. 



74 DISEASES OF FEMALE ORGANS OF GENERATION. 



(r) OVARIAN DROPSY. 



The ovaries of the human female are not larger 
in their natural state than a pigeon's egg. They are 
liable from disease to be distended so as to form an 
immense sac, containing an enormous quantity of 
fluid, either in one cyst, or in many. In the latter 
case, the disease is called the encysted dropsy of the 
ovaries. In ovarian dropsy, a tumour, or induration, 
of small size and extent, may be discovered by pres- 
sure on the abdomen just above the groin, and will, 
perhaps, be best ascertained by a rotary motion of 
the fingers, which receive, obscurely, something 
like the impression of a ball situated deeply in the 
pelvis. It is of great importance that the practi- 
tioner should have an opportunity of ascertaining 
the existence of this tumour in an early stage : if he 
is first called to a patient suffering under this dis- 
ease when the whole abdomen has become enlarged, 
he must take the description of its first appearance 
upon trust ; and it is not always easy to obtain from 
the patient a clear account of the origin or progress 
of the disease. He will, however, on inquiry, gener- 
ally learn that the tumour commenced on one side 
of the abdomen, and extended from thence all over it. 
The existence of fluid in the abdomen may be gener- 
ally ascertained by placing one hand flat on one side 
of the abdomen, and striking the opposite side of the 
abdomen with the other hand; but the fluid is not 
always to be discovered by this mode of examina- 
tion, if it is either unusually thick and viscid, or if 
it is contained in innumerable cysts. The disease 
may be mistaken for physconia omentalis. The pa- 
tient walks about, looks healthy, the only inconve- 



OVARIAN DROPSY. 75 

nience being that of a distended abdomen ; and this 
exemption from constitutional derangement, or the 
usual symptoms of disease, affords an additional 
ground of distinction between ovarian dropsy and 
ascites. The constitution, however, at length be- 
gins to suffer, the abdomen becomes more distended, 
the patient loses flesh, the system becomes exhausted, 
and death finally ensues. On examining those who 
have died of ovarian dropsy, the ovaries are found 
to contain in different cases different kinds of fluid, 
which may be in one, two, or three, or in a greater 
number of cysts. The contained fluid may be thin 
and watery, or it may resemble bloody water ; it 
may be of the consistence of gruel, or a complete 
jelly. The quantity differs in each case ; it may 
vary from a few quarts to ten or twelve gallons. So 
large a quantity has been drawn off from a patient 
by the operation of tapping, that the fluid has been 
placed in one scale and the patient in the other, and 
the former has preponderated. 

The general object of treatment is to excite the 
action of the bowels and kidneys by hydragogue 
purgatives, or by diuretics and mercury; these 
means, however, produce but trifling diminution of 
the tumour, and often disorder the general health 
more than they reduce the size of the abdomen. 
The enlargement of the belly increases ; the patient 
can bear the distention no longer. You tap her, and 
the abdomen becomes flat and flaccid ; but it fills 
again ; and every succeeding time you draw off the 
fluid a greater quantity is evacuated, and a less space 
of time elapses between each operation. The con- 
stitution becomes debilitated, and the health more 
disturbed. Irritation from the puncture may extend 
to the cyst, and produce inflammation there, attend- 
ed by heat of skin, a tender belly, and a quickened 
pulse : to subdue these symptoms the patient's con- 
stitution is further reduced. On the next tapping 
the fluid is mixed with pus. At last there is an 



76 DISEASES OF FEMALE ORGANS OF GENERATION. 

attack of inflammation, which is fatal; or the patient 
dies from irritation and exhaustion. As the common 
mode of treatment generally fails, Hunter and Darwin 
suggested a radical cure, by extirpating the ovaries 
when comparatively small. I have been surprised, 
on a post mortem examination, to find that the dis- 
eased ovary had acquired no preternatural adhesions. 
The proper time for the extirpation of an ovary must 
be when the tumour is small : but we are not, per- 
haps, in this stage quite certain that the ovary is 
diseased; and the patient suffers so little from it, 
that it is not likely she would submit to the opera- 
tion.* 

Some practitioners have attempted to cure this 
disease as you cure hydrocele, by injection. The 
result has been unsatisfactory. Others have recom- 
mended keeping the wound open, after tapping, with 
a bougie, by which the fluid is permitted constantly 
to dribble away, in order that the cyst might con- 
tract : the wound then becomes a fistulous opening, 
and, the cyst ceasing to secrete, it finally heals. This 
method has been practised many times, and the pa- 
tients have been cured. I have frequently seen it 
done, and very little inflammation has ensued : in 
one instance the inflammation was very considera- 
ble ; but it was subdued ; adhesion took place in the 
cyst, and there was no return of the complaint. In 
a patient of my own, after the second tapping, in- 
flammation supervened, with great pain, a rapid 
pulse, &c. I bled, purged, and blistered, and the 
inflammatory action subsided. She had no return 
of the dropsy. I have since tried this method of 
treatment, but have not been equally successful. 
The patients were much emaciated, and their con- 

* The operation for the removal of the diseased ovaries has 
lately been performed with success by Mr. Lizars and others. 
See Observations on Extirpation of the Ovaria, with Cases, by 
Mr. Lizars ; Edinburgh Med. and Surgical Journal, vol. xxii. 
p. 247, and vol. xxiv. p. 174. 



OVARIAN DROPSY. 77 

stitution broken down ; inflammation was excited by 
the wound, and death ensued. On examination, the 
belly was found to be distended with a puriform 
fluid. Had I succeeded in several cases, I could re- 
commend this treatment with confidence : but as I 
have succeeded only in one, I do not feel justified in 
such recommendation. It is, however, proper that 
this should be mentioned among the expedients 
which have been proposed for the cure of this disease. 
The choice lies between these three modes of treat- 
ment : — First, evacuate the fluid by tapping as often 
as the belly is sufficiently distended. Second, tap 
and keep the wound open. Third, defer tapping as 
long as you can. The last I believe to be the best ; 
for those live the longest whose cysts are the least 
meddled with. As by repeated tapping the fatal ter- 
mination of the disease is hastened, your efforts should 
be directed to the preservation of the general health, 
as by attention to the bowels, perhaps tonics, un- 
stimulating but nutritious diet, &c. ; and the cyst 
must be left to take care of itself. 



11 



78 OF PREGNANCY. 



LECTURE THE SECOND. 



OF PREGNANCY. 



Section I. — Theory of Conception. 

The offspring, both of animals and of plants, are 
propagated by different modes. If you place a slip 
of geranium in a pot of earth, and give it the ad- 
vantage of a favourable situation, all those parts will 
be produced which will constitute a perfect plant ; 
many vegetables, and some animals, the polypi for 
instance, may be propagated in this manner. The 
polypi are found in fresh water rivulets ; upon in- 
spection these animal bodies are found to be of a 
conical form, with a hole in the middle. If touched, 
they shrink up into a lump resembling jelly. Their 
mode of propagation is singular. If you cut off a 
piece of one of them, this portion will be developed 
into a complete polypus : nature propagates them in 
a similar way. Little warts or excrescences grow 
from the animal, fall off, and become polypi. Before 
their separation, you see other excrescences on these, 
and others again on them, so that they begin to pro- 
pagate before they are born ; that is, before their 
separation from their parents. This is the simplest 
mode of propagation. As we ascend in the scale of or- 
ganized beings, the manner of propagation is more 
complicated; so that two become necessary for the pro- 



THEORY OF CONCEPTION. 79 

duction of a third. One contains in certain organs 
the substance of the future progeny, the other sti- 
mulates, by appropriate organs, the system of its 
mate to develop this germ : the first are the organs 
of the female, the second those of the male. Some 
animals have the organs of both sexes, as the garden 
snail ; these are called hermaphrodites. Neverthe- 
less, two of these animals are necessary to complete 
the act of procreation, and this is done by a double 
copulation. 

There is but one system of generative organs in 
each individual of the higher classes of animals. In 
fishes a contact of the sexual organs is not necessary 
to procreation. The female deposits eggs, (or spawn,) 
and the male spirts his semen over them, and they 
are thus fecundated. In the frog species, the male 
stimulates the functions of the female by getting 
upon her back, and remaining there for several days ; 
at length she spawns, and he spirts his semen over 
the eggs. Some animals impregnate all the ova to 
be deposited in a certain period ; as the cock, by one 
copulation with the hen, fecundates numerous ova: 
nay, there is a species of snail, the female of which, 
though precluded from its birth any intercourse with 
the male, produces offspring, which also, under 
similar circumstances of seclusion, continue the 
species for seven or eight generations. 

In some animals the germ of the offspring is shut 
up in a case, containing also a certain quantity of 
nourishment, as is exemplified in the egg, the ani- 
mals producing which are called oviparous : these, 
for the most part, build nests, and there deposit their 
ova, keeping them warm by an action of instinct termed 
incubation, until the young burst the shell and escape 
from their confinement. Some animals have a nest 
in their body, where their eggs are deposited, and 
these are denominated ovo-viviparous, as the Surinam 
frog, which lodges her eggs on her back. The kan- 
garoo lodges the germ of the future animal, in 



80 OF PREGNANCY. 

a very minute state, in a pouch in the under 
part of the abdomen; others do not deposit the 
germ, as an egg, externally, but the ovum is still 
contained in the animal in which it was formed, in 
which it becomes fixed and rooted, and draws its 
nourishment from the parent until the period of its 
being born alive, as in the human species, and in 
most animals with which we are familiar : they are, 
therefore, called viviparous. 

The propagation of the species, whether among 
animals or vegetables, consists in the separation of 
a certain portion from themselves, which has the 
peculiar power of living, growing, and becoming 
like its original : the slip of geranium, and the ovum 
of the animal, are similar in this respect. What is 
the nature of the substance which displays the sin- 
gular power? An opinion has been entertained, 
that no process of animal organization could pro- 
duce this peculiar substance, and that it had its 
origin at the creation of man : this is the doctrine 
of Epigenesis, and its advocates maintain, that as 
there was only one creation, so when Adam and Eve 
were created, all future beings were created also. 
This hypothesis arose from the difficulty of compre- 
hending how the phenomena could be otherwise ex- 
plained. Baron Haller entertained this absurd hy- 
pothesis. The modern notion, which supposes that 
the blood-vessels of the ovaries have the power of 
secreting and of depositing a substance of the kind 
in question, is a little more rational. We know that 
the stomach first digests all the materials of which 
the body consists, and that the secerning vessels de- 
posit them in the form of bone, muscle, nerve, brain, 
&c. An elephant is a graminivorous animal, yet 
his secerning vessels transform the grass into flesh-; 
and if grass can be thus changed, I do not see why 
food may not also be converted into the vesiculaa 
Graaffianse. 

It has been thought that the male produced the 



THEORY OF CONCEPTION. SI 

germ, but it is the female who produces and retains 
it. When microscopes were first applied to the 
purposes of physiological research by Leuwenhoeck, 
he examined the semen of male animals, in which 
he saw, or thought he saw, animalcules moving 
about in different directions ; and these he affirmed 
to be animals in miniature of the same kind as those 
in whom they were produced. Even in the time of 
Harvey, the discoverer of the circulation of the blood, 
all that was known about conception was, that if a 
male copulated with a female, in a certain number 
of days after impregnation a foetus might be dis- 
covered in the uterus of the female, but how it came 
there the philosophers knew not. Harvey, in the 
reign of Charles II., was allowed to kill and dissect 
deer at all periods after impregnation : the ovaries 
were not suspected by him to be important parts of 
the organs of generation. To De Graaf we are in- 
debted for the present theory. He examined the 
generative organs of rabbits at different periods after 
impregnation, in order to ascertain what change had 
taken place in them. In thirty-six hours he found 
the* ovaries had undergone a change : these, in the 
unimpregnated state, contain a number of small 
vesicles filled with a transparent gelatinous fluid, 
which, after their discoverer, have been called vesi- 
cuke Graafnanse. At this period, one of these vesi- 
cles was found to be elevated, and to project on the 
surface of the ovary like a minute nipple ; in about 
forty-eight hours this enlarged vesicle had disap- 
peared, and a cavity was left behind. What had 
become of it ? There could be but one road ; the 
ovaries at this period, were firmly embraced by the 
fimbriated extremities of the Fallopian tubes, which 
in the natural state are at a little distance from the 
ovaries, and but slightly attached to them ; — he said 
the vesicle must have proceeded through the Fallo- 
pian tube into the uterus. He endeavoured to trace it 
by slitting up the tube, but he did not at first succeed 



82 OF PREGNANCY. 

in discovering it ; after repeated experiments he 
found it in its passage to the uterus ; and remaining 
loose for a few days in the cavity of this viscus, it 
then acquired an adhesion to its inner surface. He 
killed other rabbits each succeeding day, which had 
been impregnated at the same time, and he saw the 
ovum gradually assume the shape of a rabbit, the 
development of which he continued to observe until 
it had attained the full period of foetal growth. 
Although he took considerable pains to demonstrate 
that the germ or ovum was originally formed in the 
ovaries, and thence descended through the Fallopian 
tube into the uterus, no one believed him. Haller 
could not discover the ovum in the Fallopian tube ; 
and the fact was not received until confirmed by 
Dr. William Hunter, who went expressly to a rabbit- 
breeder at Chelsea, accompanied by Mr. Cruick- 
shank,* in order to verify or disprove the statement 
of De Graaff. They saw in the Fallopian tubes of 
rabbits more ova in their descent from the ovaries 
of the uterus, than had been stated in the account of 
De Graaf, 

Having thus far pretty clearly shown one part of the 
process of generation, the action of the male semen 
next became a subject of speculation with philoso- 
phers. It stimulates the ovum to development. How 
does it act ? Does it obtain a contact with the ovum ? 
Some said it did ; others said the ovum was impreg- 
nated by an aura which arose from the semen, and 
passed up the uterus through the Fallopian tubes to 
the ovaries. Either would have a very difficult pas- 
sage. Dr. Haightonf performed numerous experi- 
ments on female rabbits, in order to decide this ques- 
tion. He divided both Fallopian tubes ; thus cutting 
off the communication both of the semen and its aura 
with the ovaries. He found, on putting these rab- 
bits with the buck, that they had lost all desire for 

* See Phil. Trans, vol. Ixxxvii. p. 198. f Ibid., p. 159. 



THEORY OF CONCEPTION. 83 

venery; and if compelled to take the buck, were 
barren. He also found, that if he divided the Fallo- 
pian tubes of rabbits at any period less than forty- 
eight hours after copulation had taken place, the 
process of generation was at an end. But if the ex- 
periment was deferred to about fifty hours after the 
intercourse with the buck, then the process of gener- 
ation proceeded naturally. He divided the Fallo- 
pian tube of one side only in other female rabbits, 
and found that the buck not only impregnated the 
ovary connected with the opposite tube, but that 
signs of impregnation* were visible also in the 
ovary connected with the tube which had been di- 
vided. Before these experiments were instituted, a 
corpus luteum was considered to be an infallible 
sign of impregnation having taken place. A corpus 
luteum is a dense, yellow, caseous substance, which 
fills up the cavity left by the escape or rapture of 
one of the vesiculae Graaffianse. By the experiment 
just alluded to, it is shown that a corpus luteum is 
an effect of copulation, but not an infallible sign of 
impregnation ; for corpora hi tea were discovered in 
both the ovaries of rabbits, in which a division of 
one Fallopian tube had been effected prior to copu- 
lation. The only infallible test of impregnation is 
the presence of the foetus, f 

* Corpora lutea. 

t This inference does not appear to be justified by the facts ; 
the corpus luteum may be the effect only of impregnation, of 
which the proof afforded by the presence of the foetus in the uterus 
could not be afforded if the Fallopian tube were divided ; if cor- 
pora lutea are the consequences of copulation without impregna- 
tion, it may be presumed that the ovaries of most married women, 
to say nothing of those ladies of a certain profession, would ex- 
hibit more of these appearances than are generally remarked in 
them. Corpora lutea are sometimes found in the ovaries of vir- 
gins ; of their importance, therefore, as signs of conception, no- 
thing is satisfactorily known. See a paper on the passage of the 
ovum, read by Sir E. Home, Philos. Trans, for the year 1817, 
Part I., p. 252. 



84 OF PREGNANCY. 

One of the strongest proofs that the semen does 
not pass up the uterus and through the Fallopian 
tubes is this, — that if jou kill a doe rabbit just im- 
pregnated, and while she is warm introduce a blow- 
pipe into the vagina, you may blow, but no air will 
enter the Fallopian tubes, or even the uterus. Is 
it probable, therefore, that the semen should pass 
into it and through the Fallopian tubes ? But if you 
insert the blowpipe in a Fallopian tube, you may 
readily impel air into the uterus, and it will pass 
out from the vagina. There are some particulars 
relative to impregnation, which are important from 
their connection with medical jurisprudence. It 
may be asked what kind of copulation is requisite 
for impregnation ? It is not necessary for this pur- 
pose that the male organ should be introcruced far 
into the vagina. I was lately informed of a lady in 
whom, when in labour, the accoucheur found the 
hymen entire, so that he could not pass his finger 
into the vagina. I have met with a similar case ; 
and such instances are not very uncommon. A 
woman who is paralytic in the lower half of her 
body, or who has long been confined to her bed by 
hemiplegia and extreme emaciation,* may be im- 
pregnated. It is not necessary that the woman 
should be sensible at the time of impregnation, or 
that she should have pleasurable sensations ; for- 
some women never have, yet are very susceptible of 
impregnation. A maid at an inn, who was always 
thought to be virtuous, and bore a good character, 
began to enlarge in a way which excited suspicions 

* A case of this kind, in which the woman was much emaciated, 
and confined to her bed by hemiplegia, for at least a twelvemonth 
preceding her delivery, is communicated to the editor ; the labour 
was accomplished with tolerable facility ; but it appeared as if an 
abscess broke at the time of a pain, for there was a sudden gush 
of perhaps more than a pint of dark, offensive matter. The wo- 
man lingered for some time after her confinement, and died, as it 
was said, of cancer of the uterus. 



THEORY OF CONCEPTION. 85 

of pregnancy ; she solemnly declared that she never 
had connection with any man. At length she was 
delivered, and was afterwards brought before a ma- 
gistrate to swear to the father ; but she repeated her 
former declaration. Not long afterwards a postboy 
related the following circumstance : — That one night 
he came late to this inn, put his horses in the stable, 
and went into the house, and found all gone to bed 
except this girl, who was lying asleep on the hearth- 
rug, and, without waking her, he contrived to 
gratify his desires. This shows that impregnation 
may take place without the knowledge of the female, 
or any excitation of sexual passion. 

The urethra in men is sometimes imperfect, as 
from a stricture, which has closed the tube so as to 
prevent the passage of urine. Ulceration may take 
place in the perinseum, and a fistulous opening re- 
main, throug-h which both semen and urine are 
evacuated. Or, an imperforate urethra may be a 
natural defect, when also the urine is voided through 
the perinseum. In either case the husband cannot 
impregnate his wife ; as the semen, during copula- 
tion, escapes through the opening in the perinseum. 
Mr. Hunter, indeed, mentions a case in which he 
directed the semen which escaped from the opening 
in the perinseum to be taken up by a syringe, and 
injected into the vagina, immediately after the act of 
copulation, which was followed by pregnancy.* 

* This case is scarcely conclusive, as the wife might have tried 
a more natural method about the same time. 



12 



86 OF PREGNANCY. 



Section II. — The Gravid Uterus. 



Impregnation is followed by certain anatomical 
changes in the uterus, and other sexual organs. The 
first change which occurs is in the ovaries, which, 
in their natural, unimpregnated state, are small bodies 
of a glandular appearance, one on each side of the 
fundus uteri. Internally they look shaggy, and 
contain small vesicles filled with a transparent gela- 
tinous fluid. These are the vesiculse Graafnanse, or 
the germs of future animals, requiring for their de- 
velopment only to be stimulated by a sexual con- 
nection. If you examine an ovary a few days after 
conception has taken place, you will find on its sur- 
face a small fissure leading to a cavity, having its 
sides lined with a yellow, caseous substance. This 
is the corpus luteum. It occupies the place left by 
the escape of one of the vesiculse Graafnanse, and is 
never so large and conspicuous as at the commence- 
ment of pregnancy ; it gradually diminishes during 
the period of utero-gestation. The corpus luteum is 
at first soft, then becomes more solid, and at length 
disappears, leaving only a small fissure as a vestige 
of its having existed. Some persons will pretend to 
say, from inspection of an ovary, how many con- 
ceptions have taken place, but corpora lutea have 
been seen in virgins. No animal affords so good a 
specimen of the corpora lutea as the sow. Mr. 
Hunter spayed a sow on one side ; she did not pro- 
duce quite half the usual number of farrow, and 
ceased to breed at an earlier period than a perfect 
sow of the same age, though in every other respect 



THE GRAVID UTERUS. 87 

subjected to the same favourable circumstances.* If 
you have an opportunity of examining any animal 
soon after conception, the number of corpora lutea 
will correspond with the number of foetuses. When 
a woman has conceived twins, there is a corpus luteum 
in either-ovary, and not two in one ovary. -f 

Conception having taken place, the uterus under- 
goes a considerable change. It becomes greatly en- 
larged. In its unimpregnated state it will not con- 
tain a substance larger than an almond ; but at the 
full period of utero-gestation, it forms an immense 
sac, extending from the pelvis to the epigastric region, 
and will contain a foetus of nine or ten pounds, per- 
haps more, two or three pounds of secundines, and 
a quart or two of liquor amnii. It fills the anterior 
part of the abdomen, the intestines being behind. 
This enlargement conveys a sensation to the hand, 
which on many occasions, where a discrimination of 
■ the state is important, is worth attending to. The 
gravid uterus is hard to the touch ; the viscera soft 
or tympanitic. If the woman is pregnant, the front 
of the abdomen is hard ; and the sides, from the ribs 
to the anterior superior spinous process of the ilium, 
being filled with intestines, are soft, puffy, and flatu- 
lent. If you place a pregnant woman on her back, 
at the same time relaxing the abdominal muscles, the 
centre of the abdomen will be firm and hard, the 
sides lax and tympanitic. The umbilicus in its na- 
tural state is a little hollow ; but towards the latter 
period of pregnancy it is elevated to a level, and for 
the last month prominent above the surface of the 

* See Mr. Hunter's paper on this subject.. Phil. Trans., vol. 
lxxxvii. 

t On the subject of superfoetation there has long been a dif- 
ference of opinion. It appears, however, that a new conception 
may take place while there is yet a fetus in utero, whether alive 
or dead. See a paper on this subject by Dr. Dewees, in 
Med. and Phys. Jour., vol. xvii., p. 489, and Burns's Midwifery, 
note, p. 1(17. 



88 OF PREGNANCY. 

abdomen. In spurious pregnancy, or when the 
uterus is enlarged from other causes, this criterion is 
greatly to be relied on. But when the umbilicus is 
elevated, you must not always infer that the woman 
is pregnant ; as this occurs in ascites, and is also pro- 
duced sometimes by tumours which have no con- 
nection with the uterus. 

The uterus, during its enlargement, was formerly 
thought to be stretched by mechanical distention. If 
this were the case, it would be extenuated, and 
almost membranous ; but it is not so, for the uterus 
is as thick at the end as it is in the beginning of 
pregnancy ; its increase of capacity must therefore 
evidently be a result of growth, and not of. mere ex- 
tension. Some have said that its thickness becomes, 
during pregnancy, three times greater than in its un- 
impregnated state. This is erroneous ; and I know 
how they have made the mistake. Women some- 
times die about seven days after delivery from puer- 
peral fever, &c. : they are examined ; and the uterus 
is found to be of that thickness, which is the conse- 
quence of a contraction in all its dimensions, by 
which its immense cavity is comparatively ob- 
literated. But if a woman dies just before labour, 
the uterus will be found to be of its natural thick- 
ness, which is about one-fourth of an inch. The 
changes of the uterus succeeding conception are not 
those of size only, but also of structure. The parietes 
become so soft and pulpy, that it is easy to thrust the 
finger through them ; and I warn you that if you 
have your hand in the uterus, and should, during a 
labour-pain, push your finger against it, nothing is 
more likely than that your finger will pass through 
its parietes. This softness arises from the great in- 
crease in size, which the numerous vessels of the 
uterus undergo during gestation. If you inject with 
wax the whole uterine system of vessels of a woman 
who has died, without being delivered, towards the 
end of pregnancy, you will find numerous ramifica- 



THE GRAVID UTERUS. 89 

tions of vessels as large as crow-quills on the external 
part of the uterus ; in some particular portion (per- 
haps near the fundus) you will discover an immense 
congeries of vessels of the largest size, and to the cor- 
responding internal portion of its surface the placenta 
is attached. Tear this substance away, and 3^ou will 
see that part of the uterus to which it adhered thickly 
studded with the orifices of the largest vessels of the 
gravid uterus. In those frightful hsemorrhages 
which sometimes occur after labour, the bleeding is 
not from the vessels of the whole surface of the uterus, 
but from those of this particular portion. Fortunately, 
the open mouths of these vessels undergo a considera- 
ble diminution of area by the natural contraction of 
the uterus during the separation and expulsion of 
the placenta. 

The uterus, during gestation, is not only much 
enlarged, but it is lined with a thick, pulpy mem- 
brane, distinct from its other contents. It is not a 
membrane of the ovum, but a production of the 
uterus. It is formed soon after conception has taken 
place, and before the ovum enters the uterus. It is 
called the decidua. In extra-uterine pregnancy, 
when the ovum either slips into the abdomen, or re- 
mains in the Fallopian tube, we find the uterus still 
lined with this membrane, which appears to consist 
of coagulable lymph, poured out as a consequence of 
the increased turgescence of the vessels of that organ. 
It is difficult to describe its connection with the ovum. 
The whole inner surface of the uterus, except the 
cervix, is lined by this membrane : it passes between 
the placenta and uterus, to each of which it is at- 
tached, and is called the decidua vera ; but just at 
the boundary of the placenta a portion is given off, 
which envelops the ovum, as the pericardium does 
the heart : this is the decidua reflexa. There is yet 
another portion which is also given off at the edge of 
the placenta, and which passes over the front of it : 
and thus the placenta is contained between two sur- 



90 OF PREGNANCY. 

faces of this membrane. This latter production has 
no name. There are, therefore, three portions of 
this membrane ; the decidua vera, renexa, and inno- 
minata. In the early period of pregnancy, as the 
uterus increases rapidly in size, it is not filled by the 
ovum ; the decidua vera and renexa are then at some 
distance from each other ; but at the latter period of 
utero-gestation they are in close contact, and unite 
into one membrane. 

The ovum is visible in the uterus at an earlier 
period after conception in small than in large ani- 
mals. In rabbits, the ovum may be perceived in 
the uterus about the fourth day after impregnation, 
but in sheep and deer it is not visible until the end 
of the third week. In women it is visible in the 
uterus about twenty-one days after conception. Mr. 
Ogle met with a case, and Mr. John Hunter inves- 
tigated it. The case was this : — A servant girl was 
attached to the footman of a family; and, after keep- 
ing company, as they call it, for some time, she be- 
came low spirited, and ended her life by taking 
arsenic. The cause of this rash act was inquired 
into, and there was no doubt that the footman had 
succeeded in seducing her : she apprehended preg- 
nancy ; and the menses not occurring at the usual 
time, her suspicions were confirmed : she waited only 
two days after the customary period of menstruation, 
and then took arsenic. Her fellow-servant knew 
that she expected to have been unwell on a certain 
day. — The uterus and its appendages were cut out, 
and carried to the house of Mr. J. Hunter. There 
was a corpus luteum in the left ovary, the vessels 
of which were much enlarged. The uterus was en- 
larged and turgid, and lined with the decidua, into 
which vessels had evidently shot ; but the ovum was 
not to be found.* It is now generally stated that 

* See Transactions of a Society for the Improvement of Medi- 
cal and Chirnrgical Knowledge, vol. ii., p. 63. 



THE GRAVID UTERUS. 91 

you cannot discover the ovum in the uterus with the 
naked eye, or by the assistance of the microscope, in 
less than twenty-one days after conception. On the 
other hand, Sir E. Home has very lately examined 
the uterus of a female, who had been impregnated 
only eight days previously, in which he found an 
ovum of a very minute size.* According to this ad- 
dition to our knowledge, the ovum must be visible 
in the uterus much sooner than has been hitherto 
supposed. 

The ovum at first exists in the state of a mem- 
branous egg, filled with a semi-transparent fluid, in 
the centre of which is the embryo animal. At this 
period its parietes are composed solely of two mem- 
branes ; the outer, the chorion ; and the inner, the 
amnion. But soon after it becomes attached to the 
uterus, a considerable portion of its parietes presents 
a structure of a peculiar kind. On examining the 
ovum at the full period of utero-gestation, you per- 
ceive this portion, about a span in diameter, like a 
large sponge-cake, which becomes thinner towards 
its circumference. This is the placenta or after- 
birth, as it is commonly called. The ovum is filled 
with a fluid contained within the amnion, and thence 
called liquor amnii, in which the foetus is suspended. 
The chorion has a different appearance at different 
periods of utero-gestation. If we view it at an early 
period, its whole external surface is covered with 
shaggy vascular projections ; hence it has been called 
the spongy or shaggy chorion. This shaggy and 
flacculent structure of the chorion appears to be a 
provision to facilitate the adhesion of the ovum to 
the highly vascular surface of the uterus, to which 
it speedily becomes attached, and from which, through 
the medium of the placenta, it derives its nourish- 



* See a paper on the passage of the ovum, &c., read by Sir E. 
Home, May 1st, 1817. Phil. Trans, for the year 1817, Part I. 
p. 252. 






92 OF PREGNANCY. 

merit to the full period of foetal growth. As the 
period of gestation advances, these shaggy pro- 
jections of the chorion are less obvious, and at length 
. they disappear, except near the placenta. The 
chorion also gradually becomes thinner, more trans- 
parent, and easily torn, and its blood-vessels cease to 
be visible. The internal surface of the chorion is 
smooth; and there is usually between it and the 
amnion a small quantity of gelatinous fluid, which, 
towards the end of pregnancy, becomes absorbed, 
and these membranes are then in actual contact. 

The amnion is a thin, dense membrane, smooth 
both internally and externally, and perfectly trans- 
parent, and stronger than the chorion. No vessels 
have been discovered in it even with the aid of injec- 
tions ; but vessels must exist, because, as pregnancy 
advances, the quantity of liquor amnii secreted by 
the inner surface of this membrane increases. The 
amnion is reflected over the funis forming its mem- 
branous covering. 

If the placenta be examined without unravelling 
it, it looks like a cake ; hence its name. It is a span 
in diameter, and about an inch in thickness, irregu- 
lar, and lobulated on that side which has been at- 
tached to the uterus, which also exhibits the open 
mouths of its numerous vessels. If you macerate it, 
the spongy portion separates, and nothing is left but 
a congeries of vessels. One part of it communicates 
directly with the vessels of the funis umbilicalis of 
the foetus, and the other part with the vessels of the 
uterus, but there is no direct communication between 
these sets of vessels. Thus anatomists divide the 
placenta into two portions, the foetal and the mater- 
nal. If the placenta of a woman who has died to- 
wards the end of pregnancy is injected from the funis 
umbilicalis, that which is called the foetal portion 
will be filled ; and by injecting the arterial system 
of the mother, the maternal portion of the placenta 
will also be filled ; but not a single particle of the 



THE GRAVID UTERUS. 93 

injection will pass from the vessels of the foetal into 
those* of the maternal, or from those of the maternal 
into those of the foetal portion of the placenta. The 
maternal is more spongy than the foetal portion, and 
consists chiefly of cellular membrane, and of those 
numerous vessels formerly described, which com- 
municate directly with those of the uterus. The 
foetal portion consists of ramifications of the vessels 
of the umbilical cord. 

The funis umbilicalis is composed of three vessels, 
two arteries, and one large vein : these proceed from 
nearly mid-distance between the centre and the cir- 
cumference of the placenta, and enter the umbilicus, 
or navel, of the foetus. These vessels usually run 
in a spiral direction : they are connected together 
by cellular membrane, surrounded by a viscid jelly, 
and covered by a reflected portion of the amnion ; 
the whole constituting the umbilical. cord, through 
which the circulation is maintained between the 
mother and the foetus. The length of the funis is 
commonly about two feet ; it varies, however, consi- 
derably both in size and length.* Neither nerves 
nor lymphatic vessels have been discovered either in 
the placenta or funis ; and sensations cannot be im- 
parted from either, to the mother, or the child. 

The liquor amnii, so called from the membrane 



* A few years since I was called to a case of difficult labour, 
which had continued for about forty hours : the forceps hav- 
ing failed, the delivery was accomplished by opening the head 
of the child : a tremendous flooding immediately ensued, which, 
however, was restrained by the usual means. In this case the 
foetus had attained its full growth ; it was deficient in its right 
lower extremity, in place of which there was only a sort of car- 
tilaginous projection of the size, and about half the length, of one's 
little finger : there was no funis umbilicus whatever : the placenta 
was adherent to the abdomen, and seemed to form nearly its ante- 
rior parietes. Circumstances which need not here be detailed, pre- 
vented an examination of the exact mode in which, through the 
placenta merely, without the intervention of a funis, the circula- 
tion was carried on between the mother and the child. — Ed. 

13 



94 OF PREGNANCY. 

which contains it, consists chiefly of water, with a 
small quantity of albumen and muriate of soda. "The 
use of the liquor amnii is manifest. During the 
whole period of utero-gestation, it protects the foetus 
from the pressure of the surrounding parts ; as a 
wax figure suspended in a bladder filled with water 
would not be injured by any external violence. If 
by any accident during pregnancy this fluid should 
be discharged, the membranes collapse on the foetus, 
and the uterus contracts on them ; and commonly 
within the period of twenty-four or forty-eight hours 
the action of the uterus becomes excited, and abortion 
takes place.* For this reason it is, that the mem- 
branes are sometimes punctured to produce abortion 
in those who ought not to be with child ; and there 
are those of both sexes who are sufficiently depraved 
to be guilty of this practice. The practice is no 
doubt frequently a fatal one, as the introduction of 
an instrument for this purpose is difficult without in- 
jury to the uterus. Dr. W. Hunter attempted this 
operation on a young woman at about the third month 
of pregnancy. He found that he several times punc- 
tured the cervix uteri, and the case terminated fatally. 
If this happened to one of so much anatomical know- 
ledge and skill, how much more probable must it be 
in the hands of those ignorant men, by whom, for the 
purpose alluded to, the operation is sometimes un- 
dertaken ! No doubt these attempts often prove 
fatal, but the murdered do not tell tales. 

* A case has fallen within my knowledge, in which the mem- 
branes ruptured, and the liquor amnii was discharged at the com- 
mencement of the fifth month of pregnancy ; trifling collections 
of this fluid continued to be discharged at frequent intervals during 
ten subsequent weeks : at the end of which time a living child 
was born, which survived about ten days. There was no ap- 
pearance of liquor amnii at the time of the delivery ; the funis 
was twice round the child's neck, and thus escaped the pressure 
of a contracted uterus, to which, probably, the continuance of the 
life of the child for so long a period after the evacuation of the 
water may be imputed. — Ed. 



THE GRAVID UTERUS. 95 

The os uteri, during the first stage of labour, gra- 
dually dilates ; the membranes, distended with the 
liquor amnii, form a soft cushion, which is forced by 
the action of the uterus against its mouth. But if 
the membranes are ruptured before the os uteri is 
fully dilated, this dilatation must be accomplished by 
the hard head of the foetus, and the pain and diffi- 
culty of the labour will be much increased. 

The foetus in utero has some anatomical peculi- 
arities, which require a short description. 

The thymus gland is situated in the anterior me- 
diastinum. It is of a dirty white appearance ex- 
ternally, and, if cut into, contains a milky fluid. 
This gland gradually disappears after birth, so that 
in the adult there is no vestige of it. Its use is not 
known. 

The structure of the lungs of a still-born child is 
nearly as solid as that of the liver : they are of a red- 
dish, brick-dust colour, and do not contain air. But 
if a child has breathed, the cells of the lungs are in- 
flated, and being filled with air, a detached portion 
of their substance will float in water. On the other 
hand, if the child has not breathed, and if no gas has 
been evolved by putrefaction, the lungs being still 
in their condensed state, a portion of them, if placed 
in water, will sink. You may sometimes be request- 
ed to give your opinion in a court of justice on the 
question, whether a child was still-born ! A young 
woman, whose pregnancy had been suspected, is 
supposed to have murdered her child as soon as it 
was born ; the body is found, and you are called 
upon to ascertain whether the child has breathed. If 
it has breathed, the lungs will float : if not, they will 
sink in water. But this experiment is inconclusive ; 
for the child may be still-born, and the woman her- 
self may attempt to restore life by blowing down its 
throat. If she has done so with considerable force, 
the lungs will be as completely inflated as if the child 
had breathed, and consequently they will float in 



96 OF PREGNANCY. 

water. I have inflated the lungs of a still-born child, 
and they floated in water as if the child had breathed 
some days. The internal putrefy sooner than the 
external parts of the body. The child might be 
dead before it was born ; putrefaction may have com- 
menced in the lungs ; thus air is generated, fills the 
cells of the lungs, and renders them buoyant. 

The most remarkable peculiarity of the foetus is 
its circulation. Its system of blood-vessels differs 
from that found in the breathing animal, and the 
blood circulates by a different route. From the in- 
ternal iliac, or hypogastric artery of the foetus, on 
each side, proceeds a branch (or rather the continued 
trunk itself of each artery) which passes upwards on 
each side of the bladder, emerges at the umbilicus, 
runs along the cord, or funis umbilicalis, and rami- 
fies in the placenta with infinite minuteness. The 
umbilical vein is formed by the convergence of in- 
numerable branches in the placenta, which finally 
unite into one vessel ; and through this vein the 
blood passes from the mother to the foetus, for the 
purposes of its nutrition and growth. This vein is 
enclosed in the funis; it passes into the abdomen at 
the umbilicus, and enters the liver at the cleft which 
separates this viscus into the right and left lobes, to 
each of which it gives off branches ; the most numer- 
ous go to the left side of the liver; one to the vena 
portse, and another considerable branch, or rather 
the continued trunk of the umbilical vein, called the 
ductus venosus, passes direct to the vena cava in- 
ferior ; those branches of the umbilical vein which 
are distributed in the liver, and also those of the vena 
portse, discharge their contents into the inferior cava 
by the venae cavse hepaticse. The superior and in- 
ferior cavse enter the right auricle of the heart. In 
breathing animals there is a complete septum or 
partition between the two auricles, which prevents 
the passage of the blood from one into the other ; 
but in the foetus in utero there is a communication 



THE GRAVID UTERUS. 97 

between the auricles. This opening or communi- 
cation is called the foramen ovale, through which 
the blood passes from the right into the left auricle. 
Thus the two auricles are filled with blood at the 
same time, and, contracting at the same time, propel 
their contents into the two ventricles ; from the left 
ventricle the blood escapes into the aorta, and from 
the right ventricle into the pulmonary artery ; which 
latter, instead of conveying all its blood to the lungs, 
disposes of three-fourths of it through a vessel called 
the ductus arteriosus, which, proceeding from the 
pulmonary artery, enters the descending aorta. By 
this apparatus nearly the whole of the blood brought 
to the heart by the cavse is sent from both ventricles 
into the aorta ; part of this blood is returned to the 
placenta through the funis by the hypogastric arte- 
ries, and the remainder is distributed through the 
vessels of the foetus. Thus the blood in the aorta is 
impelled synchronously by the force of both ventri- 
cles ; which is probably no more than is absolutely 
necessary for the accomplishment also of the more 
distant circulation of the placenta. Immediately on 
the child being born, and respiration taking place, 
the circulation is admitted through the lungs, the 
foramen ovale becomes closed by means of a valve, 
and its permanent obliteration is soon effected. Those 
vessels, also, which were alone subservient to the 
circulation of the foetus in utero soon become oblite- 
rated, and exist only as ligaments of trivial or no 
use ; whilst that portion of the circulation of the 
liver connected with the ductus venosus now be- 
comes a part of the circulation of the vena portse. 

The liver in the foetus is remarkable for its dispro- 
portionate size to that of the other organs. The 
capsular renales are two glandular bodies, situ- 
ated above the kidneys, one on either side ; in the 
foetus they are larger than the kidneys themselves, 
and usually contain a little fluid ; they gradually 
diminish towards the adult state : their use is not 



98 OF PREGNANCY. 

known. The kidneys are large, and of a tabulated 
structure. The intestines of the foetus contain a dark 
semi-fluid substance called meconium ; this was 
formerly considered to be black bile, secreted by the 
liver, but it has been ascertained to be a secretion of 
the intestines themselves. Bodies have been ex- 
amined, in which there was no communication 
between the small and large intestines, both ending 
in a cul-de-sac ; yet the latter were filled with this 
fluid. Its use is unknown. 



Section III. — Position of the Child in Utero. 



This nature has ordered, in an admirable way, to 
embrace two objects : the first, the birth of the child 
in the most favourable manner ; and the second, the 
occupation of the least possible space. Generally 
the head of the child lies downwards, immediately 
over the os uteri ; this position has many advantages, 
the largest part makes its way first, and the others 
follow with facility. In footling cases, the smallest 
part presents first ; the largest are expelled with 
difficulty, and with great risk to the life of the child. 
It is remarkable with what regularity the occiput of 
the child lies towards the pubes of the mother, and 
the face to the sacrum, inclining towards the right 
sacro-iliac symphysis. You find this disposition in 
every common labour ; and, as the child is expelled, 
you will observe that the face turns to the right thigh 
of the mother. It accommodates itself to the shape of 
the pelvis during its passage. 

The child occupies as little space as possible. Its 



OF THE SIGNS OF PREGNANCY. 99 

length is merely that of the body ; the thighs are bent 
on the body, and the legs on the thighs ; the face is 
pressed forward on the chest, and between it and the 
knees a space is left, which is occupied by the arms. 
When Dr. Hunter was taking a drawing of the posi- 
tion of the foetus in utero, the celebrated painter 
Hogarth came in, and observed, that it was an ex- 
cellent living specimen of retirement from the 
world. 



Section IV. — Of the Signs of Pregnancij. 



Women generally know when they are pregnant, 
by certain symptoms which are commonly conclusive 
in ninety-nine cases in a hundred ; but in the hun- 
dreth they are deceptive. A suspension of the menses 
at the accustomed period of their return, generally 
confirms the suspicion of pregnancy in the mind of a 
woman who has reason to expect it. • She may have 
conceived immediately after the last menstrual period, 
or immediately preceding that which should succeed 
to it. Some women pretend to know the exact time 
of conception, but their assertion is not to be relied 
on. Soon after conception the stomach often be- 
comes affected with what is termed morning sick- 
ness ; on first awaking the woman feels as well as 
usual, but on standing up a qualmishness begins, 
and whilst dressing, or putting a tooth-brush into her 
mouth, retching takes place. In two or three months 
certain changes maybe observed in her breasts ; they 
swell and enlarge, with pricking and darting sensa- 
tions, like those attending the commencement of 



100 OF PREGNANCY. 

menstruation. The colour of the areola round the 
nipple, which, in the virgin, is of the beautiful pink 
tint of a young rose-leaf, now becomes changed to 
a dull brown, more or less dark in different cases. 
In those who have blue eyes, fair complexion, light 
hair, &c, this change does not appear till late in 
pregnancy ; but in those of dark hair, eyes, and 
complexion, the colour of the areola soon becomes 
deep. In the third month, and not before, the belly 
begins to enlarge, and gradually increases in size till 
the full period of utero-gestation. Between the six- 
teenth and the twentieth week after conception the 
uterus ascends out of the pelvis, and the motion of 
the child is felt; the period of the ascent of the uterus, 
which is termed that of " quickening," varies in dif- 
ferent women. The first time the woman expe- 
riences the motion of the foetus, the sensation is like 
that of the fluttering of a bird within her, and so 
sadden that she frequently faints, or falls into an 
hysterical paroxysm. There may be an interval of 
days between the recurrences of this sensation ; it 
afterwards increases both in frequency and degree. 
A sensation of tickling, or of pushing, is occasionally 
felt ; or the child gives a kick, or a jump, and this 
with so much energy as to move the petticoats, or a 
book, or any light article placed in the lap. It is 
important to remember these symptoms, and the 
order in which they occur : — first, cessation of the 
menses ; second, morning sickness ; third, swelling, 
and darting pains in the breast, and dark colour of 
the areola round the nipples; fourth, the gradual 
enlargement of the abdomen ; fifth, the movements 
of the child. Women rely so much on these symp- 
toms that they engage the nurse and accoucheur ; 
and in ninety-nine cases out of a hundred they are 
right, but in one in a hundred they are wrong. The 
symptoms are not infallible. They are for the most 
part present when a woman is pregnant ; but a wo- 
man is not always pregnant who experiences similar 



OF THE SIGNS OF PREGNANCY. 101 

symptoms, which may ensue from disease. The 
suppression of the menses may arise from other causes 
besides pregnancy ; it would, however, be considered 
a sign of this state in those married women who 
have hitherto menstruated with regularity. But if 
it occurs in females of a delicate and puny habit, and 
who have been accustomed to menstruate irregu- 
larly, it is a very dubious sign of pregnancy. Sick- 
ness may arise from various causes, some of which 
have been formerly enumerated. The breasts may 
be full and large, attended with pricking and darting 
sensations, without pregnancy. Great stress is laid 
on the colour of the areola round the nipples : 
and in a first pregnancy, (after which the brown 
colour, in a greater or less degree, becomes perma- 
nent,) it is a very important sign; but in chronic 
uterine inflammation I have known this dark brown 
colour produced, together with fulness and pricking 
pains in the breasts. The belly may be enlarged 
from other causes, as dropsy of the ovaries, or ascites. 
And movements very similar to those occasioned by 
the presence of a child may occur, without preg- 
nancy, from disorder of the digestive organs, accom- 
panied by an enlarged abdomen. There is scarcely 
any one symptom of pregnancy which may not arise 
from other causes; and, on the other hand, preg- 
nancy may exist without being accompanied by the 
usual symptoms, or they will be slight and equivo- 
cal until pregnancy is far advanced. I have seen a 
dozen cases, in which women for the first few months 
after conception have had discharges from the vagina 
which could not be distinguished from those of 
menstruation. 

What are you to do when the nature of the case 
is doubtful ? You must postpone giving a decisive 
opinion, till such time has elapsed as will enable 
you to ascertain, first, whether the enlargement of 
the belly is in consequence of an enlargement of the 
uterus ; and second, whether the increased bulk of 

14 



102 OF PREGNANCY. 

that organ is occasioned by the presence of a living 
child. You must ascertain this both by an examina- 
tion of the abdomen externally, and by an exami- 
nation per vaginam. Some practitioners have said 
that you can discover the presence of a foetus after 
two months of pregnancy have elapsed ; but it can- 
not be done so early as this. Dr. Wm. Hunter stated 
that examinations could not be relied on with con- 
fidence even during the first four or five months; 
but that in the sixth, or just at the commencement 
of the seventh month of pregnancy, you could pro- 
nounce with certainty on the nature of the case. 
Therefore postpone the examination, and of course 
your final decision, till the completion of the sixth 
month, and then you may be pretty correct, if you 
have arranged in your own mind what you are to 
seek for before you commence the examination. 
The seventh month, then, is the best period for an 
examination, and you have two points to ascertain : 
the first, that the enlarged belly depends on an en- 
largement of the uterus ; and the second, that the 
bulk of that organ is occasioned by the presence of 
a living child. In the first place, make an exter- 
nal examination of the abdomen. Here you have 
three objects of attention : first, the navel ; second, 
the solidity of the abdomen; third, the motion of 
the child. 

(1.) The navel in advanced pregnancy is raised 
at least to a level with the surrounding integuments, 
but is generally above them. This is invariable in 
pregnancy, and is one of the best guides. If it is 
depressed as it is naturally, there is a little thimble- 
like cavity, and there is no pregnancy ; upon which 
criterion the notorious impostor Johanna Southcote 
was pronounced correctly to be not pregnant. 

(2.) If the .enlargement of the abdomen is of a soft 
and yielding nature, and will admit of any depres- 
sion of the anterior part when the hand is firmly 
pressed on it, the increase of size can scarcely depend 



OF THE SIGNS OF PREGNANCY. 103 

on pregnancy. In a pregnant woman, at an advanced 
period of gestation, the abdomen, in front, presents 
a resistance as hard as a board, and it is a little puffy 
at the sides, beneath the ribs. 

(3.) You may be so lucky as to apply your hand 
on the belly just as the child moves : if it is quiet, 
you will often make it move by applying a cold 
hand (which, if requisite, may be immersed for a 
minute or two in cold water) suddenly on the abdo- 
men ; or by allowing the hand to rest for a few 
minutes, with a moderate pressure, on the abdomen, 
some movement of the child will frequently be felt. 
If you find the navel raised, the belly hard in front, 
and can feel the movement of the child, you have 
not much occasion to proceed farther ; but if you 
still doubt, you must examine per vaginam, in which 
examination you have also three points of attention — 
first, the state of the cervix uteri ; second, the body 
of the uterus ; third, the movement of the foetus. 

(1.) During the first three or four months of preg- 
nancy, the cervix uteri projects as far into the vagina, 
is just as long, and hard, and the os tincse conveys 
the same impression to the touch, as in the unim- 
pregnated state. About the fifth month the cervix 
becomes shorter, softer, and broader, and thus it goes 
on progressively. In the seventh month the neck of 
the uterus is diminished to about half its former 
length, and a harcl tumour, which is the head of the 
child, may be distinguished through it. At the end 
of the eighth month the cervix is completely obliter- 
ated, becoming a portion which has assumed the 
general shape of the uterus. 

(2.) You direct your attention to the size of the 
uterus by moving the cervix, thereby causing the 
whole to move;- a sensation will be imparted, by 
which you can ascertain whether the body of the 
uterus is enlarged and heavy, or whether, moving 
lightly, there is no enlargement of it ; feel also whe- 
ther there is a bulky, solid tumour between the cer- 



104 OF PREGNANCY. 

vix uteri and the symphysis pubis. If the circum- 
stances of the case render its nature still doubtful, 
(though it is a dirty trick,) pass your finger up the 
rectum, when, if the uterus is enlarged, you will 
feel it bulging backwards into the hollow of the 
sacrum. 

(3.) The head of the child rests on the cervix uteri 
and symphysis pubis. Place your finger midway 
between these two points, and suddenly push the 
tumour in a perpendicular direction, and in a moment 
or two, you will feel something drop on the top of 
your finger, indicating that a floating something has 
been pushed up, and then subsided into its proper 
place. Having thus ascertained these six points, 
you should be able to pronounce on the question of 
pregnancy with confidence. 

There are three classes of persons by whom you 
are likely to be consulted, namely, young unmarried 
women, who will solemnly assert that they are not 
pregnant yet have big bellies, &c. ; women with 
ovarian dropsy ; and married women who think they 
are pregnant when they are not. I will give you a 
little advice relative to the unmarried class. Never 
give an opinion till six months have elapsed since 
the last menstruation. Do not believe one word 
they say. Listen to them as you would to a jockey 
praising his horse. A medical man requested me 
to accompany him a few miles in the country to see 
a young lady in fashionable life, who had a peculiar 
tumefaction of the abdomen, and milk in her breasts, 
to which he did not attach any importance. When 
we arrived, he said he had brought an accoucheur, 
a friend of his. I was permitted to examine her as 
I pleased. I laid my hand, which is naturally cold, 
on the abdomen, and felt the child move ; the navel 
was raised, and the belly hard. This was enough to 
satisfy me ; but as it was expected that I should do 
everything that was customary, I introduced my 
finger into the vagina, found the cervix uteri obliter- 



OF THE SIGNS OF PREGNANCY. 105 

ated, and a hard tumour resting on the symphysis 
pubis, and, on pushing it upwards, I felt the child 
drop again on my ringer. I went down stairs, and 
told the medical man she was with child. He was 
astonished. In six weeks after I delivered her of a 
child. I have met with many similar cases. Never 
rely upon the evidence of their tongues, but on that 
of their bellies. 

An enlargement of the abdomen from ovarian 
dropsy sometimes gives rise to the suspicion of preg- 
nancy. In these cases, if seven months have elapsed 
from the commencement of the enlargement, you will 
perceive, when you pass the finger up the vagina, the 
cervix uteri of its natural length and size ; and you 
will otherwise discover that the character of the tu- 
mefaction is different from that of the gravid uterus. 
Women are liable to fall into a state in which their 
digestive organs are greatly disordered, attended with 
suppression of the menses and enlargement of the 
abdomen ; they engage their nurse and accoucheur, 
and there is no pregnancy. Women about forty -five 
years of age, when the menses are about to leave them, 
are the most likely to become thus affected ; but these 
symptoms may occur in earlier life. A young man and 
woman fell in love with each other, and although their 
parents objected, they contrived to get married un- 
known to them ; they returned respectively to their 
homes, and lived with their parents to keep all quiet, 
but used to meet now and then. At length the female 
became sick in the morning, her abdomen tumid, so 
much so that her sisters remarked what a large belly she 
had ; the young married female, taking it for granted 
that she was pregnant, as she had full breasts, morn- 
ing sickness, and a cessation of her menses, con- 
fessed her marriage, and a house was taken, in which 
she lived with her husband. At about seven months 
from the commencement of her symptoms I was con- 
sulted ; when, on feeling her abdomen, and finding 
it soft, I expressed a doubt as to the nature of her 



106 OF PREGNANCY. 

case. I then examined per vaginam, and discovered 
the cervix uteri as long as in the unimpregnated 
state, and upon this evidence asserted that she was 
not pregnant. I put her under a plan of treatment, 
consisting of purgative medicine every morning, so 
as to procure four or five evacuations daily, together 
with tonics. After this plan had been followed ten 
days, the purgatives were given only every second 
day : under this treatment she became perfectly well. 
A lady was sent me by Sir Astley Cooper for the 
purpose of ascertaining whether she was pregnant ; I 
examined, and found her not so. I gave her every 
morning pulv. jalap, comp. 9ii., and directed her 
to keep a measure of the abdomen ; in a few days 
it was lessened half an inch; every day it be- 
came smaller ; and in a few months her symptoms 
had entirely left her. I see these cases often, and 
they are cured by the combination of purgatives with 
tonics ; but of these means the purgatives are the 
most essential. 



Section V. — Diseases of Pregnancy. 



The natural period of pregnancy is nine months. 
This period is liable to be abridged by peculiar states 
or circumstances incident either to the uterus itself, 
or to other parts of the system. To speak first of 
the latter. During pregnancy the head, chest, sto- 
mach, liver, bowels, &c, are liable to consequent de- 
rangements : pregnant women frequently suffer from 
headache, sense of throbbing, or giddiness. These 
symptoms depend on one of two causes, either upon 



DISEASES OF PREGNANCY. 107 

too great a fulness of the vessels of the head, or upon 
a disordered state of the stomach and bowels. Some 
cases of this kind are relieved by bleeding, others by 
purging in a more remarkable degree. When we 
prescribe, we must be guided by general constitu- 
tional signs ; if the patient is of a full habit, with a 
florid countenance, and a strong, firm pulse, the symp- 
toms most probably arise from a determination of 
blood to the head ; she may have been many years 
regularly preparing six or eight ounces of blood more 
than was necessary for the support of the system, 
which was as regularly evacuated by menstruation ; 
but pregnancy taking place, this discharge is sus- 
pended : and as the foetus, during the first month or 
two requires but little for its support, plethora may 
succeed to the cessation of an accustomed discharge ; 
the symptoms are, therefore, relieved by the abstrac- 
tion of eight ounces of blood from the arm, together 
with such purgatives as will procure two or three 
evacuations daily, a spare diet, and abstinence from 
fermented liquors. When the affections of the head 
are moderate, they seldom produce any serious con- 
sequences ; when the determination to the head is 
more considerable, it sometimes produces short fits 
of blindness, or there is an appearance of sparks or 
flashes of light, &c. ; these symptoms musthe watched 
with great attention, for they may end in puerperal 
convulsions; and the depletion must be active in 
proportion to their severity. When affections of the 
head occur in females of weakly and delicate consti- 
tutions, being produced by disordered stomach and 
bowels, indicated by a furred tongue and unnatural 
secretions, they are not usually relieved by bleeding ; 
here the treatment must consist of purgatives, by 
which the system will be relieved of the vitiated se- 
cretions of the alimentary canal ; afterwards tonics 
may be given. 

Pregnant women sometimes suffer from nervous 



108 OF PREGNANCY. 

irritation, which occasions palpitations of the heart, 
and congestion of the lungs, with dyspnoea. In 
some instances the symptoms are the common ones 
of inflammation of the chest, as violent cough, diffi- 
cult breathing, hot skin, and a quick, hard pulse. 
Such remedies must be employed with vigour as 
abate inflammatory actions. Abstract fourteen ounces 
of blood ; and, if this bleeding does not give relief, 
you must repeat it, adopting an antiphlogistic treat- 
mentf in other respects till the circulation is tranquil, 
and the cough easy. Small doses of opium and 
hyosciamus may sometimes be given to relieve irri- 
tation, when there is no reason to suppose the dis- 
order to be of an inflammatory kind, or when the 
inflammatory action, if it before existed, is subdued 
by appropriate treatment. 

Towards the latter end of pregnancy haemorrhage 
from the lungs may occur, attended with cough and 
expectoration, full pulse, and hot skin. I cannot 
say what connection this has with an inflammatory 
action ; these symptoms are, however, relieved by 
the antiphlogistic remedies. If a patient, when in 
labour, suffers from pulmonary haemorrhage, there is 
an urgent reason for hastening the delivery of the 
child, which I should accomplish as soon as the 
head was within reach of the forceps.* 

It is remarkable that pregnant women scarcely 
ever feel sick until they first get on their feet in the 
morning, and hence it is called the morning sickness; 



* The editor is informed of a case in which the haemorrhage 
from the lungs was copious at the commencement of a labour ; 
it was treated by bleeding, followed by an active purgative of calo- 
mel, salts, and jalap : as the labour advanced, the haemorrhage 
diminished, and finally ceased ; the woman was delivered natu- 
rally, and did well. This case is not adduced as a general pre- 
cedent; but, in addition to the medical treatment suggested by it, 
the recollection of it may, perhaps, prevent a premature, or, in 
some instances, unnecessary employment of instruments. 



DISEASES OF PREGNANCY. 109 

at breakfast they have no appetite, and experience 
some nausea ; as the day advances the sickness goes 
off, and at dinner their appetite is pretty good. This 
irritability of the stomach often arises from a foul 
state of the alimentary canal, or from plethora of the 
vessels of the stomach. The symptoms are relieved 
by medicines which evacuate the alimentary canal ; 
by allaying irritation ; and by taking blood from the 
epigastric region by means of leeches, or else from 
the arm. This sickness often ceases spontaneously 
after the period of quickening. The morning sick- 
ness is best prevented by allowing the patient but 
small meals of light nutritious diet, by attention to 
the bowels, saline draughts, and regular exercise. 
Thus, give an effervescing draught in the morning, 
allow a scanty diet of light nutritious food during 
the day, and give such an aperient every night as 
will insure one or two evacuations the following 
day. The purified extract of aloes is the best medi- 
cine, and two grains are usually a sufficient dose. 
Patients seldom ask our advice on account of this 
common indisposition, but follow that which is recom- 
mended to them by nurses and others : when they do 
consult us, there is in general a good deal of derange- 
ment of the bowels, indicated by furred tongue, cos- 
tiveness, &c, which is best treated by small doses 
of the purified extract of aloes, to which an equal 
quantity of the extract of hyosciamus may be added 
if it should occasion griping. Some practitioners 
begin with emetics in these cases, and they often do 
good ; but you must inform your patients of what is 
intended, as they have a great aversion to emetics. 
When the bowels have been well purged, and the 
tongue has become clean, prescribe tonics ; as the 
diluted sulphuric acid with infusion of columba, or 
other slight bitters. You will not succeed in reliev- 
ing your patients, if you do not proportion the quan- 
tity of their food to the diminished powers of the 
digestive functions. But patients do not like to be 

15 



HO OF PREGNANCY. 

put upon short allowance; as they cannot eat at 
breakfast, they make up for this deficiency by eating 
as much as possible at dinner and supper, in conse- 
quence of which their sleep is disturbed, and they 
become feverish. 

Sickness during pregnancy is not always oc- 
casioned by disorder of the digestive functions. In 
such cases the nausea arises from uterine irritation, 
with which the stomach sympathizes. Some women 
are sick every time they copulate, so intimate is the 
sympathy between the stomach and the sexual organs. 
These are cases of irritation of the stomach, induced 
by the particular state of the uterus. To relieve the 
irritability of the stomach, give soda in the effer- 
vescent state with peppermint water. I have found 
a fourth part of the following mixture, given three 
times a day, of great use : — Magnesia, one drachm ; 
tinct. columbse, half an ounce ; distilled peppermint 
water, five ounces and a half. Delicate stomachs 
will not bear peppermint water, made, as it com- 
monly is, with the essential oil. Diet must be strictly 
attended to, the plan of which cannot be better than 
that which you hear so often recommended in this 
place by my able colleague, Mr. Abernethy. 

If the irritability of the stomach is very obstinate 
and distressing, give no nourishment at all at this time 
for twelve hours ; if the mouth is dry, moisten it with 
a little cold water, afterwards allow a small quantity 
of food, perhaps some weak chicken broth ; prohibit 
the taking of food again during the next six hours, 
and direct the patient to drink once at about the 
middle of this period. Many cases, which have 
resisted all other means, have been much relieved by 
this treatment. Dr. Vaughan speaks of the powerful 
influence of opium and starvation, when properly 
regulated. A lady had taken various remedies with- 
out benefit, and it was thought the vomiting was now- 
kept up by habit. It was, therefore, proposed that 
she should abstain from all food four-and-twenty 



DISEASES OF PREGNANCY". HI 

hours, at which time her appetite returned, the 
vomiting ceased, and she recovered. Opium is not 
requisite in all cases of irritable stomach ; but in 
those of unusual obstinacy it may be given with 
advantage. Keep the stomach empty ten or twelve 
hours, and let the patient take half a grain of opium 
every six hours. In some cases of this description 
there is a hot skin, a rapid circulation, with pain and 
tenderness about the prsecordia: these symptoms 
require blood-letting, as from the arm, to the amount 
of eight ounces, or by the application of a dozen 
leeches to the pit of the stomach. The abstraction 
of blood greatly relieves this sub-inflammatory or 
plethoric state of the stomach : mild saline aperients 
are also to be directed, together with the recumbent 
position. In sea-sickness it is a common experience, 
that persons who are immediately sick on sitting or 
standing upright, are perfectly free from this dis- 
tressing affection so long as the recumbent posture 
is strictly preserved. 

Pregnant women are frequently troubled with 
cardicdgia. This is a symptom also of a disordered 
state of the digestive organs. An acid is formed in 
the stomach, it rises into the oesophagus, and from 
the sensation it produces is called " heart-burn." 
Women know that a little chalk or magnesia relieves 
this complaint, we therefore seldom hear anything 
of it; but if consulted respecting it, the best remedy 
I am acquainted with is ten drops of the solution of 
the subcarbonate of ammonia, and fifteen grains of 
magnesia, with an ounce of distilled peppermint 
water, taken three times a day. 

Towards the latter period of pregnancy, women 
are subject to pains in the right hypochondrium, and 
sometimes in the left. The pain at first is slight. 
They suffer little in the morning, but a few hours 
after dinner the pain becomes more violent; they are 
obliged to lie on the sofa, and generally make pres- 
sure over the part with their hand ; it does not pro- 



X12 OF PREGNANCY. 

duce abortion, but it is very distressing. I believe 
it to proceed from irritation of the liver ; for nothing 
relieves this complaint so speedily as those cathartics 
which act on the liver. The mercurial are much 
more effectual than the common cathartics. When 
the symptoms are very severe, apply ten or twelve 
leeches to the part, and promote the bleeding by warm, 
water. Give a brisk purge of calomel and compound 
extract of colocynth ; after which keep the bowels 
relaxed, with three grains of pil. hydrargyri and 
three grains of the purified extract of aloes, given 
every night. The wife of a medical man had suf- 
fered severely from the above symptoms ; she had 
been bled, had taken opiates, and various remedies, 
without any benefit : at length her stools were ex- 
amined, and they were found to be black. The pil. 
hydrarg. and extract of aloes were given, and after 
taking a few doses, the symptoms, which had resisted 
all other medicines for weeks, were removed. 

One of the most troublesome states incident to the 
latter period of pregnancy, is that of constipation. 
The bowels of women are costive at all times, but 
much more so during pregnancy. Dr. Denman 
thought it a natural state, and that it should not be 
interfered with. Sometimes a week elapses without 
an evacuation. Hence there is an extraordinary ac- 
cumulation of faeces, which gives rise to colic, tenes- 
mus, frequent desire to evacuate the bowels, the at- 
tempt at which is followed only by a thin, watery 
discharge. The complaint is sometimes supposed 
to be diarrhoea, and chalk is given ; but if the finger 
is introduced into the vagina, the rectum will be felt 
distended with an immense heap of hardened faeces. 
If consulted by a woman far advanced in pregnancy, 
who has thin, watery evacuations, succeeding to pre- 
vious costiveness, and attended with pain, weight, 
and pressure about the rectum, rely on it the symp- 
toms are occasioned by an accumulation of hardened 
faeces, and you must ascertain this by an examina- 



DISEASES OF PREGNANCY. 113 

tion. The sigmoid flexure of the colon is sometimes 
filled with indurated faeces, which at times produce 
inflammation, and sloughing of the gut, and death. 
A costive state of the bowels during the latter period 
of pregnancy may induce peritoneal inflammation 
after delivery. Many cases of sporadic peritoneal 
inflammation after delivery doubtless arises from this 
cause. What I mean to state is, that a costive and 
loaded state of the intestines is capable of producing 
peritoneal inflammation ; therefore, both before and 
after delivery this costive state should be guarded 
against. Should inflammatory symptoms appear, 
the proper treatment is to bleed, and to unload the 
bowels by purgatives. 

The motion of the child, if this can be called one 
of the diseases of pregnancy, is often so violent as to 
alarm the mother. So strong and unpleasant is it in 
some cases, that it occasions sleepless night, or, if the 
patient does sleep, she has often frightful dreams. 
This seems to show that corporeal states, as well as 
external causes, convey ideas to the mind, or have 
an influence upon it during sleep. I have lately been 
told by two different patients that in a dream they 
supposed themselves to be walking in the street, and 
that a man, who was driving a cart, insulted them, 
and gave them a kick on the belly, and, on awaking, 
they have been conscious of a violent rolling and 
kicking of the child. The remedies which afford the 
greatest relief are bleeding, when not otherwise ob- 
jectionable, to the amount of a few ounces, gentle 
aperients, and opium. It is a question whether opium 
has any sedative influence on the child, or whether 
it acts by diminishing the sensibility of the uterus to 
its impressions. In some cases relief is obtained by 
these means, whilst in others they fail, the patients 
are, however, consoled by this proof, that the child is 
alive and vigorous. 

(Edema of the lower extremities is likely to occur, 



H4 0F PREGNANCY. 

without any hydropic affection in any other part of 
the body, at the latter period of pregnancy. It is 
first remarked towards night about the ankles, by 
degrees the swelling rises higher, and the legs be- 
come of a very large size. The gravid uterus, by 
its pressure, both obstructs the return of venous 
blood from the lower extremities, and also com- 
presses the absorbents. The patient goes to bed 
with her legs swollen ; towards morning her face 
swells, and the swelling of the extremities disap- 
pears, but returns as the day advances. Sometimes 
the oedema is but trifling ; at other times it extends 
not only throughout the lower extremities, but the 
labia pudendi are enlarged to nearly the size of the 
head of a child. When labour comes on, the external 
parts being in this state, the accoucheur, mistaking 
this swelling for the child's head, may suppose so 
much of the labour to be over. When first in prac- 
tice I made this mistake. I was called to a labour ; 
the pains were severe : on examination I found a 
large tumour between the patient's thighs ; and sup- 
posing it to be the head of the child, I requested the 
nurse to get everything ready. Pain succeeded 
pain, but there was no advance of the shoulders. I 
then began to examine more minutely, and found 
the tumour to consist of an immense enlargement of 
one of the labia. Had I been more attentive at first, 
I should have discovered, as I did afterwards, that 
the skin on the outer side of the tumour was con- 
tinuous with that of the upper part of the thigh, 
while the opposite side of the tumour only conducted 
the finger into the vagina. The labia may be thus 
enlarged without offering any considerable impedi- 
ment to the delivery. In general no treatment is 
required ; but if before labour comes on the swelling 
occasions much pain, I would let out the effused 
serum by a puncture with a lancet. A lady had both 
labia greatly swollen, and very painful ; she refused 



DISEASES OF PREGNANCY. H5 

to have them punctured unless I made use of my 
eyes, and the tumour which presented itself abso- 
lutely astonished me. In half an hour after an 
opening had been made into the labia, the bed was 
drenched with serum, and the patient was perfectly 
easy. I have heard of these punctures exciting in- 
flammation and producing gangrenous ulcers diffi- 
cult to heal, as scarifications in anasarcous legs some- 
times do ; but I have never met with an instance of 
the kind myself, and am rather sceptical with respect 
to its having occurred. 

Varicose veins of the lower extremities are very 
common during pregnancy. This state of the veins 
arises from the pressure of the enlarged uterus on 
their trunks, by which the return of blood to the 
heart is impeded. The remedies for this state of 
the veins are pressure, cold applications, and the re- 
cumbent posture. Pressure should be employed 
according to Mr. Baynton's method. First strap 
the leg with adhesive plaster, then apply over this a 
roller bandage with a moderate degree of tightness, 
and keep this bandage wet with common or with 
Goulard water. Practitioners are generally cautious 
in the employment of pressure, lest in consequence 
of a compression of the superficial veins of the legs 
congestion should occur elsewhere. To prevent this 
you must, in conjunction with pressure, take away 
a few ouuces of blood, and direct an abstemious diet, 
at the same time keeping the bowels relaxed by 
aperients. 

Pruritis, or an itching of the pudenda, as I have 
before stated, is a common symptom in pregnancy. 
The most effectual remedy is the abstraction Of blood 
from the part, by the application of eight or ten 
leeches, and when they fall off the bleeding should 
be encouraged by using a sponge and warm water. 
The mucous membrane of the vagina is inflamed and 
turgid with blood, and hence the relief afforded by 
topical bleeding. I have now given you some account 



116 OF PREGNANCY. 

of the most important diseases of parts more or less 
intimately connected with the uterine system which 
occur during pregnancy. I shall next proceed to 
notice the diseases, or preternatural circumstances, 
to which the uterus itself is liable during this state. 



Section VI. — Retroversio Uteri. 



When retroversion of the uterus takes place it is 
in general between the third and fourth month of 
pregnancy. In the year 1754, Dr. William Hunter 
was in the following manner first made acquainted 
with its occurrence. A poor woman in London, 
about four months advanced in pregnancy, was sud- 
denly seized with retention of urine. She sent for 
Mr. Walter Wall, a medical practitioner, who passed 
the catheter, and relieved her ; but the impediment 
continued, and it being again necessary to employ 
the catheter, Mr. Wall on this occasion made an 
attentive examination with a view to discover the 
nature of the obstruction. He passed his finger up 
the vagina, the course of which, instead of being 
upwards and backwards towards the sacrum, was 
upwards and forwards against the pubes. He could 
not feel the cervix uteri, but he discovered a tumour 
at the posterior part of the vagina, which, on the 
introduction of the finger into the rectum, was found 
to be between this gut and the vagina. The lower 
portion of this tumour being projected towards the 
pubes, the impediment to the evacuation of the blad- 
der was supposed to be occasioned by its pressure 



RETROVERSIO UTERI. 117 

on the urethra. Retroversion of the uterus had been 
already spoken of on the continent ; the cervix uteri 
was described as being thrown forward against the 
pubes, and the fundus to have fallen into the hollow 
of the sacrum. Mr. Wall finding that the case of 
his patient corresponded with this description,* 
endeavoured to replace the uterus, but without suc- 
cess. He then sent for Dr. William Hunter, who, 
upon examination, found the relative state of the 
parts to be that which has just been described. On 
raising the tumour, the urine dribbled away; Dr. 
Hunter attempted to restore the uterus to its natural 
situation, but failed ; there was obstinate constipa- 
tion, and in a few days the patient died. On ex- 
amination after death the bladder was found dis- 
tended, the cervix uteri was turned upwards and for- 
wards against the symphysis pubis, and the fundus 
had fallen downwards and backwards into the hollow 
of the sacrum ; where it was so impacted as to be 
with difficulty dislodged. This case being the first 
of the kind which had been noticed in this country, 
excited great interest. Dr. Hunter gave a public 
lecture on the occasion over the body of the patient, 
in which he recommended puncturing the membranes 
in order to procure abortion — a project which has 
never, happily, been carried into effect. Another 
case of a similar kind occurred shortly afterwards : 
the patient could neither pass urine nor faeces. 
Attempts w^ere made to empty the bladder by means 
of the catheter, but without success ; it was proposed 
to puncture the bladder above the pubes ; the patient 
w 7 ould not submit to this operation. At length she 
felt something burst, which proved to be the bladder, 
and in a few hours afterwards she died. The dis- 

* This complaint was first described by Mons. Gregoire in his 
medical lectures, given at Paris in 1746. Mr. Wall was one of 
six English students who attended these lectures, and the circum- 
stances seem to have escaped the recollection of them all until it 
was revived by the present case. 

16 



118 OF PREGNANCY. 

placement of the uterus was found, after death, to be 
similar to that just described. Retro versio uteri may 
terminate fatally by one of three modes ; either by 
irritation, by inflammation, or by sloughing of the 
bladder. In the first case of this kind which I ever 
saw death was produced by inflammation. The 
patient was in the fourth month of pregnancy. She 
had been suffering from retention both of urine and 
fsecesnine days, and her abdomen was immensely 
distended. The village apothecary had been giving 
her nitrous aether as a diuretic. I introduced the 
catheter, by keeping the point close against the pubes, 
and drew off several quarts of urine, with which 
were mixed puriform and bloody streaks. She suf- 
fered great pain in the region of the bladder, ac- 
companied with the usual symptoms attendant on 
inflammation ; but, in spite of bleeding and purga- 
tives, she died. On examination, the uterus was 
found to participate in the inflammation of the blad- 
der; it was still retroverted, though labour pains 
came on, and she miscarried soon after the urine 
was drawn off. It is generally believed that the 
uterus will regain its proper place when relieved of 
its contents ; in this case it was otherwise, the 
fundus being found after death below the promontory 
of the sacrum. 

The practical lesson inculcated by these facts is 
this ; if you are called to a woman at about the third 
or fourth month of pregnancy, suffering under reten- 
tion of urine, you must make an examination : and if 
you find the course of the vagina to be upwards and 
forwards, instead of upwards and backwards, with a 
tumour at its posterior part pressing on the rectum, 
you may conclude that the retention of urine is pro- 
duced by a retroversion of the uterus. The state which 
predisposes to retroversio uteri is thought to be a pel- 
vis of too great capacity : and the cause which some 
times immediately produces it, is a distended bladder, 
the neck of which rising up behind the symphysis 



RETROVERSIO UTERI. 119 

pubis, the connected cervix uteri is dragged up along 
with it, and the fundus falls down into the hollow of 
the sacrum. 

In the treatment of this complaint there are three 
principal objects : the first is, to restore the displaced 
uterus, if possible, to its proper position; if this 
should not be practicable, the second is, to keep the 
bladder free from distention, by the use of the cathe- 
ter, as often, and for as long a period, as may be re- 
quisite; the third is, to guard against inflammation 
of the bladder or contiguous parts by an antiphlo- 
gistic regimen and treatment. Before any attempt 
is made to restore the uterus to its place the bladder 
should be emptied by the catheter,* and the rectum 

* On all occasions the catheter should be introduced under the 
clothes of the patient, by which an exposure, which is rarely ne- 
cessary, will be avoided. It is directed to introduce the catheter 
by first placing the patient on her back, with her knees drawn up 
and bent ; but this position is neither a delicate nor a convenient 
one. The woman should be placed on her left side, as at the time 
of labour, and her hips should be brought rather over the edge of 
the bed; the fore-finger of the left hand is to be introduced within 
the vagina, and the point of it is to be slowly drawn in a direct 
line under the arch of the pubes out of the vagina, and towards 
the clitoris ; just as the point of the finger is drawn out of the 
vagina, by a careful examination a fleshy eminence will be dis- 
tinguished, which, being pressed, will give the sensation of the 
fleshy margin of a small orifice. Supposing the orifice of the 
urethra to be thus felt, as it must, if the point of the finger is 
drawn slowly and carefully from the vagina under the arch of the 
pubes towards the clitoris, the catheter is to be passed with the 
right hand along the fore-finger of the left, which still presses 
upon the orifice of the urethra, and b,y which the point of the ca- 
theter will be conducted into the urethra. The instrument is then 
to be passed into the bladder, at which it soon arrives ; and that 
the catheter is passing through the urethra may be ascertained by 
feeling it, with the fore-finger of the left hand, through the vagina, 
and not in the vagina. The female urethra is, in general, con- 
siderably shorter than the female catheter ; but in retroversio 
uteri the neck of the bladder is projected upwards, by which the 
urethra is elongated; in this case the female catheter will some- 
times scarcely enter the bladder, and a patient has been left, after 



-,20 OF PREGNANCY. 

by an injection ; then place the patient on her hands 
and knees, introduce the finger into the rectum, and 
make pressure against the fundus uteri. The uterus 
is sometimes so low that your finger passes beyond 
it; an ill directed pressure from the rectum may 
force it down still lower ; therefore first push it up- 
wards by your finger in the vagina, and then endea- 
vour to complete the reduction by pressure on the 
uterus from the rectum, not directly upwards, to 
which the promontory of the sacrum will be an ob- 
stacle, but rather to either side, or towards either 
sacro-iliac symphysis where there is the greatest 
space, and then upwards. The degree of pressure 
employed may be pretty considerable, and it may be 
continued for ten minutes ; if the uterus is once felt 
to move from its preternatural position, it rises easily 
into its proper place. We will, however, suppose 
that an adequate pressure has been made for a suffi- 
cient length of time, but without success; it will 
then be necessary, in order to prevent distention of 
the bladder, to draw off the urine with a catheter 
three times in every twenty-four hours. Thus you 
obviate the principal danger ; and as pregnancy ad- 
vances, the uterus will rise spontaneously out of the 
pelvis, in this way accomplishing a natural cure. In 
addition to the regular employment of the catheter 
during the state of retroversion of the uterus the 
bowels, which from the pressure of the uterus, would 
otherwise suffer from accumulation of faeces, must 
be kept constantly relieved by gentle laxatives. The 

an introduction of the short catheter under these circumstances, 
with a bladder still enormously distended by urine. In a case of 
this kind, if the urine does not flow freely on the introduction of 
the female catheter, it is best to introduce a flexible male catheter, 
by which the bladder will certainly be emptied. The urine, as it 
flows, may be received in a basin under the clothes, and when this 
is full, the orifice of the catheter is to be closed by the finger till 
this basin is emptied, or another is provided. 



RETRO VERSIO UTERI. 121 

diet should be light, and not stimulating; and the 
recumbent position should be preserved, until the 
uterus has resumed its natural place. 

The uterus, when reduced by pressure, frequently 
again becomes retro verted. It must be again re- 
placed, and a sponge pessary must be introduced, 
which will effectually prevent a similar occurrence. 
The uterus, in the unimpregnated state, may become 
retroverted, perhaps two or three days after delivery, 
or even in a woman who has never been pregnant. 
When the uterus is enlarged by disease, it is also 
liable to this displacement, attended by its usual 
consequences. I was lately requested by a young 
practitioner to see a woman who had been delivered 
three days ; he said she had retroversion of the uterus. 
I thought he meant an inversion, but on examination 
I found his designation to be correct. My finger 
passed upwards and forwards ; there was a tumour 
at the back of the vagina, between it and the rec- 
tum ; she had retention of urine, and a difficulty in 
passing the faeces, together with pain in the pelvis. 
This, I said, will have a natural cure ; the uterus 
will be daily getting smaller ; therefore take care of 
the bladder, and let the uterus take care of itself. 
The urine was regularly evacuated by the introduc- 
tion of the catheter twice or three times a day ; in 
about a week all the symptoms vanished, and on 
introducing my finger into the vagina, no vestige of 
the complaint could be discovered. I was consulted 
by an elderly woman, past the period of child-bearing, 
who had bearing down, with pain in the pelvis, and 
great difficulty in passing urine and fseces. I ex- 
amined per vaginam ; my finger passed upwards and 
forwards. There was a tumour at the back of the 
vagina, between it and the rectum. I placed her on 
her hands and knees, and readily pushed up the 
tumour from the rectum. 

The treatment of this complaint is the same in all 
cases ; and may be thus summed up. Reduce the 



122 OF PREGNANCY. 

retroverted uterus if practicable ; if you fail in this 
attempt, draw off the urine twice or three times in 
every twenty-four hours ; apply leeches to the lower 
part of the abdomen if any degree of inflammation is 
indicated by tenderness on pressure ; keep the bowels 
regularly evacuated by castor oil ; direct a light, 
unstimulating diet, together with the recumbent 
posture. This disease when first known was fatal ; 
but now if you are called in early to a case of this 
description, the death of the patient will perhaps also 
be the death of your reputation. 



Section VII. — On Abortion. 



The natural period of pregnancy is nine calendar 
months ; but many causes may excite the uterus to 
a premature expulsion of the ovum. Writers make 
a distinction between abortion and premature labour. 
If the expulsion of the ovum occurs before the sixth 
month, it is called abortion ; if afterwards, premature 
labour ; but this is an arbitrary distinction, for the 
process in both instances is analogous. The symp- 
toms which usually precede abortion are pains, going 
and coming, in the region of the uterus, together 
with a discharge, per vaginam, of coagulable blood. 
When a woman is about to miscarry, she knows it 
by these signs. Sometimes the irritation of the uterus 
is communicated to the neighbouring organs, and 
there is a desire to void urine and faeces, although 
the bladder and rectum may be empty. At other 
times there is great irritation of the nervous system, 



ON ABORTION. 123 

indicated by hysterical affection. But the discharge 
of coagulable blood, attended by a sense of weight 
in the pelvis, with intermitting pains, are the only 
symptoms to be relied on; and after these have con- 
tinued for a period, which varies considerably in dif- 
ferent cases, the ovum is expelled, and the pains and 
discharge cease. But these symptoms may cease 
suddenly, while the ovum is expelled from the 
uterus only into the vagina ; here it may remain 
harmless and unirritating, until an attempt perhaps 
is made to evacuate the bowels, when the ovum is 
expelled also from the vagina ; and hence it is not 
unfrequently discovered in the close stool. At an 
early period after conception, the ovum generally 
comes away entire, and on immersing it in water, 
its external appearance is shaggy. But at a more 
advanced period of pregnancy, the membranes burst, 
and the liquor amnii and foetus alone are expelled ; 
the placenta is left behind, and some days may elapse 
before it comes away. Sometimes the ovum escapes 
in a clot of blood, and being overlooked, it becomes 
a question whether or not abortion has occurred. 
Every clot of blood should therefore be inspected. 
On examination of the ovum, the foetus will be found 
suspended in it by the umbilical cord : there are in- 
stances, however, in which it has appeared to be a 
mere bag, in which no foetus could be discovered. 
Dr. Hunter explained this anomaly, by supposing 
that the foetus had perished, and was dissolved or 
absorbed : this is a mere conjecture, to w T hich may 
be opposed the equally probable one, that an ovum 
may be produced which never contained a foetus. 

The causes of abortion are very numerous ; they 
may, however, be arranged generally under these 
three divisions. First, those which, stimulating the 
muscular fibres of the uterus, excite their contraction, 
and the foetus is expelled. Second, those which pro- 
duce a separation, partial or complete, of the ovum 



124 OF PREGNANCY. 

from trie uterus, in consequence of which, the foetus 
may die ; it then excites the uterus to an expulsive 
action, as an extraneous body. Third, those, the 
primary action of which is on the foetus, such as 
powerful mental emotions, by which, as by a sudden 
shock, its death is occasioned ; it is then also ex- 
pelled as a foreign body. Thus abortion may be^ 
^produced by the excitement of the muscular fibres j 
of the uterus ; by the separation of the ovum, or by 
the death of the foetus. The discrimination, how- 
ever, of these modes respectively, is not easy in all 
cases. Irritation in the neighbouring parts may oc- 
casion abortion, as that produced by a calculus in the 
bladder, or by accumulation of faeces in the bowels. 
Abortion may also ensue from falls or local injuries, 
from fright or violent passion. There is a kind of 
revelling at Norwich, in the celebration of which a 
man is dressed up fantastically, and something re- 
sembling the head of an alligator, with hideous jaws, 
is placed on his shoulders. This hero with the alli- 
gator's jaws is, from the action attempted by them, 
appropriately called " Jack Snap." A pregnant lady 
happened to be going through the market, without 
being prepared for such a spectacle ; she saw this 
thing peeping over her shoulder. She was struck 
with terror and fainted, was carried home, and almost 
immediately miscarried. In this case the sudden 
alarm which she experienced caused the muscular 
fibres of the uterus to contract, and the ovum was in 
consequence expelled. There is no doubt that pas- 
sions and emotions of the mind sometimes destroy 
the child ; but how an influence of this kind is com- 
municated from the brain of the mother through the 
umbilical cord to the child, is not easily determined. 
Some miles from London lived the daughter of a 
gardener, who was seduced by an officer of dragoons. 
Thev lived for some time together as man and wife, 
and she became pregnant. At length he fell in love 



ON ABORTION. 125 

with a female of his own rank, and married her. 
When this circumstance became known to the gar- 
dener's daughter her affliction was extreme. She 
spent the day in tears and hysterical paroxysms : 
and from the moment at which she first received the 
intelligence she never felt the child move. She had 
the sensation of a cold, heavy lump in the region of 
the uterus, and the breasts suddenly became flaccid. 
Three weeks afterwards pain came on, accompanied 
with a discharge from the vagina. I was requested 
to see her, when I learnt the above particulars. A 
dead child was expelled. Such examples are very 
numerous. Abortion in other instances cannot be 
traced to any external obvious cause. At a certain 
period of pregnancy women will sometimes miscarry 
in spite of your best endeavours to prevent it. There 
are two classes of females particularly disposed to 
spontaneous abortion — the nervous, and the plethoric. 
Abortion is supposed to arise in nervous women from 
a participation of the uterus in the susceptibility in- 
cident to this temperament, by which it is liable to 
be easily excited to an expulsion of its contents. 

In women of a plethoric habit the vessels of the 
uterus may be ruptured from over-distention, and 
abortion follows. Thus, it is said, in the one class 
abortion is produced by nervous irritation of the 
uterus, and in the other by fulness and consequent 
rupture of some of its blood-vessels. But I think it 
generally commences with the death of the foetus. 
I attended a lady of a very pale complexion, who, 
at a certain period of pregnancy, had miscarried 
repeatedly. Soon after my arrival the ovum was 
expelled. It had the appearance of having been dead 
several weeks ; the foetus was quite brown and fetid, 
and the placenta was covered with tubercles. This 
morbid state of the placenta had no doubt caused the 
death of the foetus. Another case occurred in which 
the foetus died at about the third month after con- 
ception ; yet it was not expelled from the uterus until 

17 



126 OF PREGNANCY. 

the end of the full period of gestation. This hap- 
pened to the same patient twice, and each time the 
placenta, called in this state, by Mauriceau, " scir- 
rhous," was hard and almost cartilaginous. 

There are three different stages in cases of this 
description, at which our advice and assistance 
may be required. First, we may be called upon 
to prevent abortion, when it is merely apprehended ; 
secondly, to prevent it when the process has 
already commenced; and, thirdly, to conduct the 
patient safely through it when its occurrence is 
inevitable. 

The means which are the most likely to prevent 
the spontaneous abortion incident to women of a 
nervous temperament, are those by which the health 
of such may be improved under any other circum- 
stances. These will consist chiefly of tonic medi- 
cines, pure air, nutritious but unstimulating diet, and 
the cold bath. Mr. White of Manchester gives dilute 
sulphuric acid three times a day, and directs the 
use of the tepid bath at about 86 degrees, every second 
morning, on an empty stomach. The latter, though 
in some sort an empirical recommendation, is one 
worthy of considerable reliance. The best plan, 
though this is not always successful, is to separate 
those women from their husbands who are accus- 
tomed to spontaneous abortion before conception has 
taken place, by sending them to the sea-side, where 
their constitutions may be invigorated by cold bath- 
ing. If their health is good at the time of conception 
they will, perhaps, have a living child at the end of 
the customary period of gestation ; but if the health 
is bad at this time, abortion will ensue under the best 
management. If conception succeeds to a course of 
sea-bathing, the use of the cold bath may be con- 
tinued with advantage at proper intervals during the 
whole period of pregnancy. 

We have now to speak of spontaneous abortion in 
women of an opposite state of the system,— in those 



ON ABORTION. 127 

of a plethoric habit, who have red cheeks and a full 
pulse. Here the general object of treatment is to 
keep the circulation low and tranquil ; a few ounces 
of blood should be taken from the arm at each of the 
three first menstrual periods after conception ; the 
bowels should be kept relaxed, the diet should con- 
sist of vegetables, with abstinence from fermented 
liquors, and none but the most gentle exercise should 
be permitted. A lady of plethoric habit, who had 
been accustomed to miscarry, and had tried without 
success the usual remedies, together with absolute 
rest, in her next pregnancy consulted me. I pre- 
scribed the same treatment, but directed her to take 
gentle and regular exercise daily on a pony, at only 
a walking pace. The irritability of the system 
subsided, and she has since had three or four living 
children. 

When a woman has miscarried several times 
about the same period, the foetus being expelled 
about three weeks after its death, a mild mercurial 
course, consisting of a grain of calomel with five 
grains of the extract of hyosciamus every night, may 
have the effect of changing the unhealthy action of 
the uterine system. The operation of this medicine 
will require to be watched, and it will be the more 
beneficial if carried so far as to produce some ten- 
derness of the gums, when it should be discontinued ; 
and regular evacuations should afterwards be pro- 
duced from the bowels by means of castor oil, or 
some mild aperient. 

Those women who menstruate with difficulty and 
pain seldom conceive, and if they do, they generally 
miscarry. When speaking of dysmenorrhoea I stated 
that this complaint occurred in two varieties of con- 
stitution, and that two empirical modes of treatment 
were proposed for its relief or cure. One was said 
to consist in a mild mercurial course, as a grain of 
calomel every night, with hemlock, opium, or hyos- 



128 0F PREGNANCY. 

ciamus ; and the other in the exhibition of camphor, 
in ten grain doses, during the menstrual period, to- 
gether with a drachm of the volatile tincture of 
guaiacum, increased to three drachms at a dose, 
three times a day, during the intervals of menstrua- 
tion. I recur to this subject for the purpose of in- 
forming you that I have now three patients under 
my care who suffer from dysmenorrhea ; one of 
these is a lady who has been married three years, 
and, though anxiously desirous to have children, has 
never yet been pregnant. I put her under the course 
of treatment just mentioned with camphor and guai- 
acum. At the first menstrual period after this treat- 
ment was commenced, she had less pain and less 
discharge than formerly ; at the second menstruation 
she had no pain, and only the customary discharge; 
and at the third period, there was neither pain nor 
discharge ; but now, on her getting out of bed in the 
morning, she feels sickness, from which you will 
readily infer the nature of her present malady. The 
other two patients are much better. In plethoric 
subjects the mild mercurial course is the most likely 
to be beneficial ; the treatment by camphor and guai- 
acum may be prejudicial, and is suited only to women 
of a pale complexion, nervous irritability, and a lan- 
guid circulation. ' I find cases of dysmenorrhea 
much more manageable under these methods of treat- 
ment than under any with which I was formerly 
acquainted. 

For the prevention of miscarriage the separation 
of the wife from her husband is an indispensable 
measure. I told one lady who consulted me on this 
subject, that she must be separated some little time 
from her husband. She replied, if I could assure 
her that it would prevent abortion, she would submit 
to it ; if not, it was quite out of the question. — You 
will not prevent abortion, although the case is other- 
wise well treated, as long as the husband is not sepa- 



ON ABORTION. 129 

rated from his wife. Frequent sexual connection 
alone will often excite the uterus to action which 
terminates in abortion. 

But supposing abortion has commenced, and on 
being called in you find the patient labouring under 
irregular pains in the back and region of the uterus, 
with discharge of coagulable blood ; here you can 
do but little to prevent the expulsion of the ovum. I 
believe the child is then in general dead, and must 
be expelled. You may sometimes, however, succeed 
in this object; and as there is a chance of success, 
you must attempt it. You have two principal points 
of attention. First, tranquilize the uterus by opium. 
Second, keep the circulation low and quiet, by ab- 
stinence, together with perfect rest in the recumbent 
position, and if there is vascular fulness by bleeding. 
I inquire if there is pain ; if there is, I give opium ; 
if the pulse is full, strong, and hard, with a hot skin, 
I bleed and give nitre, which seems to have the effect 
of diminishing the action of the heart and arteries ; I 
direct the patient to remain in bed, to be kept cool, 
and to take no warm fluids. The best method of 
giving nitre in these cases is in ten or fifteen grain 
doses every five or six hours. The nitre should be 
plunged into a glass containing about three ounces 
of cold water, and immediately swallowed, that its 
solution may, if possible, take place in the stomach. 
Some practitioners when called to a woman threaten- 
ed with a miscarriage make a regular practice of 
bleeding the patient ; but when the pulse is neither 
rapid nor full, this measure is superfluous, and may 
be prejudicial ; it is sufficient to keep the patient 
cool, to give nitre, to direct a low, cool diet, and per- 
fect rest in the recumbent posture.* These remedies 

* To these recommendations it maybe added, that small doses 
of Epsom salts in infusion of roses, such as two drachms given 
. every six or eight hours, and diminished according to their ope- 
ration upon the bowels, will sometimes prove extremely bene- 
ficial in cases of this description ; so much so, that a discharge, 



130 OF PREGNANCY. 

are all calculated to restrain haemorrhage ; when this 
is moderate, take care of the uterus, and let the dis- 
charge take care of itself. But if the haemorrhage is 
profuse, and the patient becomes faint, pallid, and 
breathless, I reverse the rule, and prefer attending to 
the haemorrhage and allowing the uterus to take care 
of itself. The chief object, when abortion becomes 
inevitable, is so to conduct the patient through it 
that the constitution may not suffer from too profuse 
a haemorrhage. When the ovum is expelled, all pain 
and haemorrhage will cease. If on examination ypu 
feel a portion of the ovum protruding through the os 
tincae, you may pass your finger up by the side of it, 
which will stimulate the uterus to contract, and 
thereby you may hasten its expulsion. But if you 
cannot feel the ovum, you must on no account leave 
a patient who has both pains and haemorrhage, for the 
latter may proceed usque ad mortem. 

The best mode of restraining the haemorrhage is 
either to place a lump of ice in the vagina, or else to 
plug the vagina with lint, or a large sponge dipped 
in vinegar. I use the plug of lint or sponge, a con- 
siderable bulk of which will be required to fill the 
vagina, which mast be done so completely that the 
escape of blood is mechanically prevented. The re- 
sult of plugging the vagina in this case is not the 
same as at the full period of utero-gestation, when the 
quantity of blood poured into the uterus itself may 
be sufficient to kill the patient. At the period of 
abortion the uterus can contain but little ; you sup- 
press the haemorrhage ; the contraction of the uterus 
continues gradually to expel the ovum behind the 
plug; and when its expulsion is thus far completed, the 

threatening miscarriage, which had continued for a week or ten 
days, under a treatment which comprised no attention to the 
bowels, has been known to cease totally in a day or two after this 
treatment has been commenced, and the woman has afterwards 
gone her full time. 



ON ABORTION. 131 

pain ceases, and the plug, foetus, and placenta, readily 
come away. 

If on the expulsion of the foetus the placenta is left 
behind, the discharge will speedily become fetid, 
and there may, perhaps, ensue considerable consti- 
tutional irritation. This state is best treated by 
giving Epsom salts in infusion of roses, with the ad- 
dition at each dose of twelve or fifteen drops of diluted 
sulphuric acid. In cases of abortion, when the pla- 
centa does not immediately follow the birth of the 
foetus, the uterus may sometimes be excited to a con- 
traction, by which it will be expelled, by the stimu- 
lation of the finger introduced within the os tincae. 
The texture of the placenta is at this period very 
weak, and it is therefore difficult to obtain a firm 
hold of it. I attended a case in which the mem- 
branes and placenta remained ten days after the ex- 
pulsion of the foetus, producing considerable irrita- 
tion. I examined and found the membranes partly 
protruding through the os tincse. I attempted to ex- 
tract them with my finger and thumb, but could not ; 
I then took a pair of nasal polypus forceps, and intro- 
duced them with care, and grasping the projecting 
portion, was enabled to extract the whole. This in- 
strument has the proper curve, and it may pro- 
bably be as useful in other cases as I found it in 
this. 



13 2 ON LABOUR. 



LECTURE THE THIRD 



ON LABOUR. 



Section I. — Natural Labour. 



At the end of nine calendar months from the time 
of conception the natural period of pregnancy is 
accomplished. How are you to calculate, so as to 
give an opinion when labour may be expected to 
commence ? A woman may menstruate at the ac- 
customed period, but on the next return of that 
period no menstrual discharge appears. The pre- 
cise time of conception, however, remains to be dis- 
criminated : it may have been soon after the last 
menstrual period, or a fortnight afterwards, or even 
only twenty-four hours before the expected return of 
the menses. This latter has been known to be the 
case when soldiers or sailors have returned, after a 
long absence, to their wives only a day or two before 
the menstrual period. 

In general, impregnation takes place a day or two 
after the last menstrual period. If you calculate on 
this supposition, you will most commonly be right. 
I ask the patient, When she was last unwell ? how 
long the discharge continued ? and from the day after 
its termination I reckon nine calendar months ; thus, 



NATURAL LABOUR. 133 

a lady tells me she was taken unwell on the 17th of 
June, and continued so four days ; I add one more, 
and from this day, being the 22d of June, I reckon 
nine calendar months, and conclude that she will fall 
in labour on the 22d of March in the following year ; 
and in a large majority of cases I am right. But 
the occurrence of conception immediately, or very 
soon after menstruation, though frequent, is liable 
to many exceptions. Some practitioners reckon from 
the middle period between the last menstruation and 
the one that should next ensue, alleging that, if con- 
ception did not take place immediately after the last 
menstruation, the patient, by reckoning from this 
time, will be kept in a state of unpleasant suspense. 
Neither mode of reckoning is infallible ; for, in the 
first place, the time of conception can rarely be known 
with precision; and, in the second, the period of 
pregnancy is not absolutely certain, it may in some 
women be more, in others less than nine months ; and 
the same irregularity occurs in brutes, as in the cow, 
mare, &c, where the time of conception is known 
and registered with the greatest accuracy. You 
may give your opinion, if it is requested, that labour 
will take place at the end of nine calendar months 
from the day after the last menstruation ; but qualify 
this opinion by saying that it may be a week or ten 
days later. 

A few hours, though sometimes several days, be- 
fore labour commences, the belly sinks, the stays 
become loose, and the woman feels light and airy ; 
and as there has been no discharge to explain this 
diminution, it must be from the sinking of the uterus 
lower into the pelvis. The motions and weight of 
the child are also felt to be lower than formerly. If 
you introduce your finger into the vagina, you will 
feel the cervix uteri nearer to the external orifice than 
it is before this subsidence takes place. At this time 
also there is tenesmus, and micturition is unusually 

18 



134 



ON LABOUR. 



frequent. The symptoms of the commencement of 
labour are pains in the back and loins, extending down 
the front of the thighs; these at first continue but a 
few seconds, and recur every fifteen or twenty 
minutes ; the patient rarely expresses the pain at this 
period by exclamation ; but if you notice her coun- 
tenance you can easily tell when the pain is on. If 
she is working or reading, she lays her work or book 
aside, screws up her mouth, lays hold of the chair, and 
there is a general appearance of uneasiness, but as soon 
as the pain is gone, she resumes her work, or takes 
up her book, and speaks just as if nothing had hap- 
pened. Pains of this kind continue for a time, ^hich 
is irregular in the different instances ; but at length 
thev affect the os uteri, which, if examined during a 
pain, will be found open, perhaps of the size of a 
shilling, or more, giving the sensation of being 
pressed against ; but when the pain is off you find the 
os uteri relaxed, soft, and yielding, and the unresist- 
ing membranes are felt behind it. As the labour 
proceeds, the pains recur more frequently, and are of 
longer duration ; the membranes, distended with the 
liquor amnii, begin to descend through the os uteri, 
and by the vis-a-tergo they produce, farther and 
farther, the os uteri becoming proportionally dilated. 
In some cases the membranes descend^ so far as 
almost to protrude through the external orifice of the 
vagina; presently a strong pain comes on, crack go 
the membranes, the liquor amnii escapes with a gush, 
deluging the bed ; there is now a longer interval 
between the pains, and on introducing your finger you 
discover a great change. Instead of a soft tumour, 
you feel a large, round, and hard substance, which 
you immediately recognise to be the head of the 
child. Again the pains recur, the patient becomes 
boisterous, expressing her pain in a very audible 
manner ; she lays hold of a towel, which is commonly 
fastened to the bed-post for this purpose, and bears 



NATURAL LABOUR. 135 

down with all her might ; her pulse now is rapid, and 
her skin hot; the expulsive process still goes on; 
the pains are more frequent, stronger, and more last- 
ing ; a degree of impatience is now manifest ; the 
head of the child descends lower and lower into the 
vagina, till it presses firmly on the perinseum. In this 
stage of the labour a young practitioner would think 
that a few pains would expel the child, but though 
the head rests on the perinseum, and presents at the 
external orifice, yet it may be some hours before 
it is expelled, more especially if it is the first 
labour ; but if the second or third, half a dozen 
pains will generally be sufficient to complete it. In 
first labours, this stage is often tantalizing and decep- 
tive ; a pain comes on, the head is propelled forward, 
and distends the perinseum ; the pain subsides, and 
the head recedes. In this manner the labour may 
continue for several hours, without making any very 
apparent advance : through this period the expansion 
of the perinseum, which is necessary to the comple- 
tion of the labour, is still going on. On examination 
you will perceive that the perinseum has by degrees 
become thinner and thinner, the external orifice of 
the vagina more relaxed and yielding ; at last comes 
a more effectual pain, the head advances, the external 
orifice is widely expanded, and, in the twinkling of 
an eye, pop comes the head of the child into the 
world. There is usually now a longer interval of 
pain ; the face of the child at its birth is almost in- 
variably towards the sacrum, and the occiput to the 
pubes of the mother. You will find, during the 
expulsion of the body, the face turn towards the right 
or upper thigh of the mother, and the occiput to the 
left or lower thigh : this is generally the case ; and 
it is so for the reason that the shoulders, being the 
widest part of the body, are made to occupy the 
greatest width of the inferior aperture of the pelvis, 
which is from sacrum to pubes. On the expulsion 
of the head, one strong pain is sufficient for that of 



136 ON LABOUR. 

the body of the child. On applying your hand to 
the abdomen of the mother, you will now find that 
it has undergone a considerable change ; instead of 
it being distended, hard, and resisting, it is flaccid, 
soft, and yielding ; and through its relaxed parietes 
you can feel, just above the symphysis pubis, a hard, 
round ball a little larger than your fist, which is the 
uterus contracted from an immense sac into this 
small compass. 

The child being born, there is a remission of pain, 
and the woman feels rejoiced at the sadden transi- 
tion from severe suffering to comparative ease. In 
about ten minutes the woman again feels pains, less 
violent than before, in the region of the uterus, com- 
ing and going about every five minutes ; on examin- 
ing, you will find a quantity of coagulated blood 
expelled, and on passing up your finger along the 
umbilical cord, you will discover the placenta forced 
into the upper part of the vagina, where, from the 
horizontal position of the patient, it may remain 
some time, if not removed by the accoucheur. The 
placenta being taken away, the labour is then over. 
These are the external and obvious changes which 
occur during the progress of labour. Some other 
important particulars are to be next spoken of; such 
as the power by which the child is expelled from 
the uterus ; the process by which the os uteri is 
dilated; the manner in which the child passes 
through the pelvis, which is a short, curved, irregu- 
lar and bony canal, of different dimensions in diffe- 
rent parts ; and the process by which the placenta 
is detached and expelled from the uterus. These 
are no speculative problems ; in the varied forms of 
difficult labour, you will sometimes find that you 
have to act as a substitute for nature, her own 
powers being inadequate ; when the knowledge of 
all these particulars will be necessary to your suc- 
cess. 

The power which expels the child resides chiefly in 



NATURAL LABOUR. 137 

the uterus itself,* which is aided in this operation by 
the diaphragm and abdominal muscles. During a pain 
the muscular fibres of the uterus contract, compres- 
sing its contents against the orifice of the uterus, 
which does not itself contract, but, on the contrary, 
becomes dilated. That this is the mode of the de- 
livery of the child is proved by many facts. The 
alternatives are either, that the child escapes by its 
own efforts, or that it is expelled by the uterus ; it 
cannot be by the former mode, for a dead child is 
born as easily as a living one, or perhaps more so. 
In the case, also, of a lacerated uterus, the child does 
not advance through the natural passage, but recedes 
from it, and escapes into the bag of the peritoneum. 
That the expulsive power resides chiefly in the uterus 
itself, the sense of touch is alone sufficient to prove ; 
for if we introduce our hand into its cavity, in the 
absence of a pain, it is felt to be soft and flaccid ; but 
upon the recurrence of pain, the hand is so firmly 
grasped by the contraction of the uterus as to be 
sometimes benumbed, and we are glad to withdraw 
it; the pain ceasing, the uterus is again soft. One 
might think this evidence sufficient; but that of 
sight, also, has been thought necessary to confirm the 
supposition of a process, which few people would be 
inclined to doubt. A Frenchman performed some 
experiments on dogs, of which he ought to have 
been ashamed. The object of these experiments was 
to ascertain whether vomiting was owing to the 
action of the stomach itself, or to that of the dia- 
phragm and abdominal muscles. He laid open the 
abdomen of a dog, and cut away the stomach, substi- 

* Anatomists agree in the fact that the uterus possesses a mus- 
cular structure, which is manifest only towards the latter period 
of utero-gestation ; they are not, however, agreed upon the pre- 
cise arrangement of its muscular fibres. 

See a paper on the Muscularity of the Uterus, by Mr. Charles 
Bell, Med. Chirurg. Trans., vol. iv., p. 335. 



138 0N LABOUR. 

tuting for it a bladder, which was attached to the 
oesophagus above, and to the pylorus below : he in- 
jected a coloured fluid into the bladder, and an emetic 
medicine into a vein ; which latter produced the cus- 
tomary action of vomiting, by which the coloured 
fluid from the bladder was ejected through the oeso- 
phagus. At the same time experiments were made 
on bitches when in the act of bringing forth their 
young, by which ocular demonstration was obtained 
that the uterus expelled its contents chiefly by its 
own contractile powers. The diaphragm and ab- 
dominal muscles render considerable aid to the uterus 
in this expulsive function ; so that if you make a 
woman bear down, as it is termed, during a pain, by 
which these auxiliary powers are called into action, 
the effect of the pain will be considerably increased. 
The os uteri is dilated both by the action of the 
fibres of the uterus, by which it is drawn open and 
upwards, and by the pressure of the contents of the 
uterus, which are forced against it by a contraction 
on all sides ; by this pressure the membranes, dis- 
tended with the liquor amnii, are made to protrude, 
in the form of an egg, further and further, with an 
increasing dilatation of the os uteri at each pain. It 
seems as if the fundus uteri were a fixed point, and 
all the fibres of the uterus contracted from the os 
tincse to that part, thus drawing the os uteri open and 
upwards, and at the same time compressing its con- 
tents, and forcing them, like a wedge, through the 
os uteri, which is thereby dilated. The rapidity and 
ease of the dilatation of the os uteri depend upon its 
own dilatability, and the force exerted to overcome 
its natural state of contraction. Practitioners often, 
when the process of dilatation is slow, conclude that 
the os uteri is rigid ; this is sometimes the case ; but 
every os uteri which dilates slowly is not a rigid one, 
of which the touch will afford sufficient proof. The 
slowness of this process most frequently arises from 






NATURAL LABOUR. 139 

the weakness or irregular action of the dilating 
powers, or else from the escape of the liquor amnu 
by a premature rupture of the membranes. The 
dilatation of the os uteri may be said generally to de- 
pend upon the contraction of the uterine parietes, 
and upon the protrusion of their contents. 

How does the child pass through the pelvis, the 
dimensions of which are so irregular ? By the most 
simple contrivance in the world. Leave the body 
of the child out of the question, it is, How does the 
head get through ? and the problem is answered ; 
for where this passes, the body easily follows. 

The pelvis is a bony canal, the superior and in- 
ferior apertures of which are both oval, but in oppo- 
site directions. Thus, if you measure the superior 
aperture of a full-sized female pelvis, from ilium to 
ilium, you will find it to be five inches and a half; 
from pubes to sacrum, four inches and a half; dia- 
gonally, five inches and a half. If you measure the 
inferior aperture, from ischium to ischium, it will be 
found to be four inches and a half; from pubes to 
sacrum, five inches and a half; thus, the greatest 
space in the superior aperture is from side to side ; 
m the inferior, from pubes to sacrum. If you measure 
from the arch of the pubes to the coccyx, you will 
find the distance to be the same as from pubes to 
sacrum above ; but in labour the os coccygis yields, 
being forced backwards about an inch, thereby mak- 
ing this, in the inferior aperture, the widest diameter. 
The depth of the pelvis varies at different parts of its 
circumference : in front, from the brim, or superior 
margin, to the inferior margin, it is an inch and a 
half; at the sides, about four inches; and at the 
back part, six inches; so that it is a short canal, oval 
above from side to side, below, from before, back- 
wards. These irregularities in the dimensions of 
the pelvis render the passage through it a curved 
one ; each aperture, therefore, has a different axis ; 



140 ON LABOUR. 

that of the superior aperture is downwards and back- 
wards, that of the inferior downwards and forwards. 
The pelvis being thus formed, in what manner does 
the head of the child pass through it ? The shape 
of the head is oval ; its longest diameter is from the 
forehead to the occiput, its shortest from side to side, 
and its course through the pelvis must be con- 
formable with these dimensions. At the commence- 
ment of labour the head descends through the supe- 
rior aperture of the pelvis, with the occiput towards 
one ilium, and the face towards the other. In this 
stage, the head in its longest dimension passes 
through the widest diameter of the pelvis; and for 
the purpose of a similar adaptation, the face after- 
wards turns into the hollow of the sacrum, and the 
occiput to the pubes. Thus, the descent of the head, 
corresponding with the apertures of the pelvis, and 
also with its axis, is first downwards and backwards 
through the superior aperture, and then downwards 
and forwards through the inferior aperture, the occi- 
put in this latter stage being turned under the arch 
of the pubes, and the face towards the sacrum. 

On being called to a patient, the first point to be 
ascertained is, whether or not she is in labour ; the 
second, whether the presentation is a natural one. 
These two particulars being known, it is next an 
object to keep up the spirits and confidence of your 
patient during the labour, however tedious it may- 
prove. The perinseum should be protected when in 
danger of laceration from the passage of the head 
through the external orifice of the vagina. The 
child being born, it remains only to tie and cut the 
funis, and to extract the placenta when it is separated 
from the uterus. 

It is of importance to all parties to decide correctly 
in the first instance whether or not your patient is 
in labour. She may have pains, which, in situation, 
continuance, and recurrence, so much resemble those 



NATURAL LABOUR. 141 

of labour, that though in reality of a different kind, 
a woman who has had many children may not be 
able to distinguish them. These are called false or 
spurious pains. They may come on several weeks 
previously to actual labour, and may continue irregu- 
larly until that period, and are exceedingly trouble- 
some. These are pains in the back and bowels, 
passing round to the loins, and they descend to the 
hips and thighs, going and coming like labour-pains ; 
during these pains there is no contraction of the 
uterus, and the os tineas is not dilated by them. The 
nature of these spurious pains is not certainly known ; 
I believe them myself principally, from considering 
their seat and course, to arise from irritation of the 
nerves of the uterus. Some attribute these pains to 
the presence of irritating matter in the intestines ; in 
proof of which they allege that they are more effec- 
tually relieved by purgatives than by any other 
remedies. This fact may perhaps prove an accumu- 
lation in the bowels, but not that the pains in ques- 
tion are caused by this accumulation. 

In order to distinguish the spurious from the true 
labour-pains, it is necessary to ascertain whether 
they are attended with a contraction of the uterus, 
and whether there is any dilatation of the os tineas. 
This information is obtained by an external exami- 
nation of the abdomen, and by an examination per 
vaginam. First, place your hand on the abdomen 
of the patient, and retain it there until the pain 
comes on ; if it is a true labour-pain, you will feel a 
large tumour, which is the uterus, contract beneath 
your hand : then pass your finger up the vagina to 
the superior and anterior part of that canal, where, 
during a pain, the orifice will be felt to dilate. Wo- 
men have a prejudice in favour of our making an 
examination per vaginam during a pain : they call 
it " taking a pain;" and this prejudice of theirs it 
will be proper to respect. The nurse perhaps says, 

19 



142 0N LABOUR. 

" The doctor wants to take a pain." The woman 
being laid on her left side, you then introduce your 
finger to the upper part of the vagina, apply it to the 
os uteri, and ascertain if, during a pain, the orifice 
opens, and whether the membranes, distended with, 
the liquor amnii, become tense and protrude a little : 
these circumstances are characteristic of a truelabour- 
pain, and if they are remarked, you may conclude 
your patient to be in labour. The examination 
which has enabled you to decide that your patient 
is in labour, will afford an opportunity also of ascer- 
taining the presentation ; for which purpose, while 
the pain is off, and the membranes flaccid, press 
your finger upwards, so as to discover what is behind 
them, or in them ; and if you feel a large, rounded, 
and hard substance, this is the head of the child, and 
the presentation is a natural one. 

I will suppose the woman not to be in labour, but 
suffering from false or spurious pains : the os uteri, 
if slightly open, as is sometimes the case, is then not 
affected at the time of a pain, neither do the mem- 
branes become tense. You must not, however, in 
this case give too hasty a prognosis ; for often in first 
labours false pains will continue for two or three 
hours, and then be succeeded by true labour-pains. 
This caution is especially applicable to first labours : 
in subsequent ones, if, during a pain, there is no 
dilatation of the os uteri, no distention of the mem- 
branes, or pressure of them against the os uteri, you 
may, with less hesitation, give it as your opinion that 
the woman is not in labour. In making your prog- 
nosis it is proper that you should ascertain whether 
the full period of utero-gestation is accomplished, 
and whether there is the subsidence of the belly 
which precedes actual labour. If the patient has 
gone her full time, and if there is the customary 
subsidence of the belly, whether it has been remark- 
ed for one or two days, or only for a few hours, even 



NATURAL LABOUR. . 143 

in a first labour, I am unwilling to believe that the 
pains are altogether spurious, or that they will not 
soon be followed by those of actual labour ; but if 
pains come on several weeks before the full period 
of utero-gestation, and are accompanied with no 
sinking of the abdomen, then, in the absence of any 
of those signs before enumerated, which would prove 
them to be of a different description, I decide such 
pains to be spurious. These pains are very trouble- 
some, and occasion much vain and anxious expecta- 
tion. They are best treated by a purgative in the 
first instance ; as by castor oil, or a black dose : and 
the bowels being cleared, the next object is to quiet 
irritation ; for which purpose you may give twenty 
drops of the tincture of opium, and direct the patient 
to remain in the recumbent posture. If these 
spurious pains are attended with a hot skin, and a 
full and rapid pulse, eight ounces of blood should 
first be taken from the arm, which is to be followed 
by the purgative and the anodyne, in the order just 
mentioned. 

It being ascertained that the patient is actually in 
labour, it then becomes a matter of importance to 
keep up her spirits and maintain her confidence in 
you until it is over. This is easily done if the labour 
is a short one ; but if it proceeds slowly, through one 
night — if the following day advances and still no 
promise of a speedy termination, the patient begins 
to doubt whether she has received proper assistance, 
and those about her look suspiciously at you : they 
calculate the number of hours the labour has already 
lasted ; they wonder it is not further advanced; and 
you are made to feel, both by looks and hints which 
are sufficiently intelligible, that your competency is . 
thought to be rather questionable. When you find 
yourselves in this situation, you will not think it a 
remarkably agreeable one. I fight this battle by 
three general rules. First, — If it is the first labour, 



144 ON LABOUR. 

I always calculate that it will be tedious ; and there- 
fore avoid, as long as I can, acknowledging my pa- 
tient to be in labour; and I am never fool enough to 
state any time within which the labour will be over. 
Second, — I never stay in the room when I can with 
propriety get out of it. Third, — I endeavour to make 
my patient pass away the time as pleasantly as pos^ 
sible, through a long and tedious period of severe 
suffering. If you allow your patient to suppose that 
she is in labour from the very first pain, she will 
speedily be exhausted, both by her own efforts, and 
by disappointment at their utter fruitlessness. You 
may say that the pains she suffers are preparatory 
to more effectual ones, for which she must wait 
patiently ; when these effectual ones come on, you 
may then concede that she is really in labour ; and 
you may assure her that it is going on well, though 
the period of its continuance is yet uncertain. 

If your presence in the room with the patient is 
not required, you had better pass as much of your 
time as possible in an adjoining one ; for, if you are 
with the patient, your interference will be expected 
when it can do no good : but, on the contrary, super- 
fluous examinations tend only to render the parts dry 
and irritable. Besides which, by being constantly 
present, you are rendered more familiar both with 
the patient and her attendants than will conduce to 
the preservation of the requisite confidence in you. 
Supposing then the stage of the labour and the na- 
ture of the pains to be such that your presence is 
not required, you had better amuse yourself with 
your own reflections in an adjoining room, by which 
your own mind will be kept composed and tranquil ; 
and as often as may appear necessary you will visit 
your patient, ascertain how the labour proceeds, and 
cheer her with hopes of its favourable and speedy 
termination, being cautious not to commit yourself 
too far in the latter promise. Much may be con- 



NATURAL LABOUR. 145 

tributed towards making the time pass cheerfully 
with your patient, by her having with her some 
agreeable friend whose conversation may amuse her 
in the intervals of pain. In some cases you will 
require all the ingenuity and address you are master 
of, to keep up the confidence of your patient : if you 
fail to do this another practitioner will be called in, 
and it will be said you could not deliver her. Never 
let another practitioner be called in during the labour, 
if by any means you can avoid it. 

The propriety of your absenting yourself from a 
patient who is in labour, will depend upon many 
circumstances, but principally upon whether or not 
it is a first labour. If it is a first labour, provided 
you can be within call, you may visit your other 
patients, return, ascertain the state of the labour, and 
perhaps go out again, &c. This you may do until 
the os uteri is dilated to the size of a crown-piece, a 
process which will occupy about two-thirds of the 
time of labour ; afterwards no prudent man would 
leave his patient until the labour is over. But if it 
is not the first child, the progress of the labour is 
very different ; the patient has slight pains recurring 
about every ten or fifteen minutes, just sufficient to 
remind her that she is in labour : the accoucheur is 
generally apprised of this state of things, in order 
that he may be in the way. On being sent for after 
a notice of this kind, you will find that these trifling 
pains have been sufficient, perhaps, completely to 
dilate the os uteri. The pains now become stronger, 
and the membranes more distended — presently they 
are ruptured — gush goes the liquor amnii ; and if 
your arrival has not been pretty expeditious, you 
may be greeted on entering the room with the squal- 
ling of the child under the bed-clothes. If I am 
called to a labour which is not the first, and find the 
pains regular, though slight, however trifling may be 
the dilatation of the os uteri, I am exceeding shy of 



146 ON LABOUR. 

leaving my patient. Whoever engages in the 
practice of midwifery, must make up his rnind to 
spend many a useless hour in the house of his 
patients ; for if he is absent when the child is born, 
they will think he ought to have been present : at 
all events, they are assured he has been of no ser- 
vice, and will grudge him his fee, or perhaps not pay 
it at all. 

During labour, your patient will require no other 
nourishment than tea or gruel, for the pains tend to 
excite febrile irritation ; she may sit on an easy chair, 
or walk gently about the room, until the os uteri is 
fully dilated. When the os uteri is fully dilated, let 
her go to bed ; after a few pains, more severe than 
the former, crack go the membranes, the liquor 
amnii escapes, and the bald head of the child begins 
to descend into the vagina : the patient must now 
remain in bed, and you must not stir from her side. 
The head descending, the perinaBum becomes thin- 
ner; it is forced out into a round tumour, and the 
head begins to protrude through the external orifice ; 
the perinaBum now requires support, lest the passage 
of the head should lacerate it, by continuing to 
descend downwards and backwards ; which it would 
do, and come out at the coccyx, were it not opposed 
by the perinaBum. You must in this stage diminish 
the pressure on the perinaBum, and compel the head 
to descend downwards and forwards, by placing the 
palm of your hand, like an artificial perinaBum, 
firmly over the natural one, and thus supporting it. 
When the pain is off we do nothing ; but when the 
pain returns we must again support the perinaBum 
firmly until it ceases : the perinaBum requires to be 
supported chiefly at its thin, extenuated edge, for 
there it first gives way. At length a more forcing 
pain comes ; this is the critical period for an adequate 
support of the perinaBum ; its thin edge slips over 
the head, which is then born. The umbilical cord 



NATURAL LABOUR. 147 

is not unfrequently around the neck of the child : 
this should be ascertained by your finger as soon as 
the head is born ; and if found to be the case, first 
gently draw down the cord a little, pass the portion 
of it surrounding the neck over the occiput, and then 
down over the face : you need not fear its breaking ; 
it will always bear a sufficient extension, or will 
always yield sufficiently for this purpose. 

Thus far we have advanced with the labour ; and 
a midwife, rejoiced at having something to pull at, 
would proceed to extract the child as fast as she 
could; but it is a horrible practice; for there must 
then be left behind a large dilated uterus. I always 
leave the uterus to expel the whole of the child ; 
first the head, by the next pain the shoulders and 
body, and lastly the extremities. I know that this 
cannot be accomplished without the contraction of 
the uterus, which prevents those untoward accidents 
which sometimes attend the separation of the pla- 
centa. After the birth of the head, there is fre- 
quently a considerable interval before the recur- 
rence of the pains requisite for expelling the other 
parts of the child ; the renewed action of the uterus 
may be excited by gently rubbing or pressing the ab- 
domen. The patient perhaps says this occasions 
pain ; which I am happy to hear, for I know and 
feel that this pain is owing to the contraction of the 
uterus. 

The child, we will suppose, is now under the bed- 
clothes; the next question to be determined is, 
whether there is only one, or more than one child ? 
To ascertain this, you place your hand on the abdo- 
men of the mother : if there is another child, the 
belly remains as hard, and nearly as large as before 
the birth of the first ; but if she has no twins the 
belly is sunk and soft, and just above the pubes you 
feel the uterus contracted into a hard tumour, about 
the size of the child's head. Supposing there to be 



148 0N LABOUR. 

only one child, we have now only to separate it from 
the mother, first tying and dividing the umbilical 
cord. Two ligatures are generally used : one is 
placed about three fingers' breadth from the umbili- 
cus of the child, and the other at the same distance 
from this towards the mother : these are to be tied 
firmly, and the cord is to be divided between them 
with a pair of scissors. The first ligature, or that 
nearest the umbilicus of the child, is necessary to 
prevent haemorrhage from the umbilical arteries, by 
which the life of the child may be in some measure 
endangered : the second ligature, or that on the side 
of the placenta, is not necessary : on the contrary, I 
prefer using only one, thereby allowing the placenta 
to empty itself of its blood, by which its bulk is re- 
duced, and it is more easily withdrawn. In cases, 
however, of twins, it is necessary to employ two liga- 
tures, between which the cord is to be divided. In 
making the division of the cord, I now always take 
the liberty to see what I am doing. I once attended 
a lady in her confinement, and after the birth of the 
child, relying on the touch only, divided the cord, as 
I supposed, between the two ligatures ; after which,' 
the child being taken away, I sat down by my patient 
waiting for the placenta to come away : presently 
the nurse came, and whispered over my shoulder, 
" The child is bleeding !" and on inspection I found 
that I had divided the cord between the navel and 
first ligature, and nothing was left but a short stump 
of the cord, which I was obliged to stitch up with a 
needle and thread, it being too short to admit of tying. 
I believe however, the bleeding would have ceased 
spontaneously, though it is highly improper to risk 
an accident of this kind. This is not the only acci- 
dent which I myself have met with at the time when 
it was my custom to divide the cord without using 
my eyes for the purpose ; and I have heard that other 
practitioners have, by a similar omission, cut off one 



ON THE MANAGEMENT OF THE PLACENTA. 149 

of the child's fingers, or a part of his penis. When 
dividing the cord, always, therefore, see what you 
are about ; this may be done without any improper 
exposure of your patient, which you must avoid by 
first tucking the clothes around her : for the nurse 
will remark any such exposure, and the report of it 
will be spread to the prejudice of your reputation. 

All anxiety with the family ceases as soon as the 
child is born ; but mine then begins : and if the 
friends of the patient knew as well as I do the dan- 
ger liable to attend the separation of the placenta, 
they would feel as I do. Of the management of the 
placenta I speak distinctly. 



Section II. — On the Management of the Placenta. 

You generally find that patients estimate their 
danger only by their sufferings ; hence, as soon as 
the child is born their anxiety ceases ; but if they 
knew the dangers attendant on the separation of the 
placenta, their apprehensions for their safety would 
scarcely terminate so soon. An immense number 
of large blood-vessels are laid open on the detach- 
ment of the placenta. If the arteries of the uterus 
are injected in a subject who dies undelivered at 
about the full period of utero-gestation, you may 
perceive on the external surface of the uterus, atone 
particular part, a cluster of contorted blood-vessels, 
elevated and conspicuous : opposite to this portion, 

20 



150 0N LABOUR. 

on the internal surface, the placenta adheres. The 
uterus being cut through, the placenta may be peeled 
away from it ; when the surface to which it was 
attached will be seen to be thickly studded with 
numerous orifices of arteries, presenting the appear- 
ance of the bottom of a cullender. These are the 
open mouths of the largest blood-vessels of the gravid 
uterus, and, from their number and size, a person 
unacquainted with the process by which the pla- 
centa is detached would suppose that its separation 
must inevitably be attended by fatal haemorrhage ; 
but this, happily, is not the case. Soon after the 
birth of the child a few clots of blood roll out of 
the vagina, accompanied with a pain indicating 
both the contraction of the uterus and the separation 
of the placenta. Nature provides against the danger 
of haemorrhage, by "a process at once simple and 
effectual. The child being born, the uterus, which 
before its birth was an immense sac filling, the belly, 
contracts into a hard ball, situated just above the 
pubes. Every portion of the uterus participates in 
this contraction, by which there is a general dimi- 
nution both of its internal and external surfaces. By 
this contraction the mouths of the vessels are closed 
in that part of the internal surface of the uterus to 
which the placenta had previously been attached : 
thus the danger of haemorrhage on the separation of 
the placenta is averted by that contraction of the 
uterus by which its separation is produced. 

Every practitioner should have his rules for the 
management of the placenta clearly defined. The 
separation of the placenta should be left to nature : 
when it is already detached, and almost expelled by 
the uterus, then you may remove it. Never attempt 
to bring it away before it is separated : you have no 
business to pull the umbilical cord till, by certain 
signs, it is known that the placenta is separated from 
the uterus. What are these signs? First, pain ; second, 



ON THE MANAGEMENT OF THE PLACENTA. 151 



a trifling discharge of coagulated blood; third, and 
most conclusive, the evidence of actually feeling with 
the finger, by a common examination per vaginam, not 
merely the termination of the cord, but the body of 
the placenta. If in five or ten minutes after the birth 
of the child the patient experiences slight pains, re- 
minding her of those she has already suffered, and 
on placing your hand on the abdomen you feel the 
uterus contracting and hardening, by this you may 
be assured the uterus is acting : wait then until the 
uterus has made a few efforts to separate and expel 
the placenta : these efforts are generally attended by 
a moderate discharge of blood, but not always, for 
the membranes may entangle and retain it. Having 
thus waited, gently take hold of the cord, pass your 
finger by its side up the vagina ; if you feel the body 
of the placenta resting on the os uteri at the top of 
the vagina, you know that it is separated. Wait 
fifteen minutes longer; you may then proceed in 
this manner to extract it — take a napkin and with it 
grasp the cord, pass your finger up the vagina, and, 
making a pulley of it, extract the after-birth in the 
direction of the upper axis of the pelvis, that is, down- 
wards and backwards. You must bear in mind that 
the membranes are very thin, and easily torn ; after 
the placenta has passed through the os tineas, the 
membranes are still behind, like the tail of a comet ; 
and as they are easily lacerated, these may be left, 
or a considerable portion of them, though the body 
of the placenta should be removed. This is pre- 
vented by turning the placenta round and round, as 
soon as it clears the os externum : thus converting 
the thin and delicate membranes behind it into the 
condensed form of a rope, when they will bear the 
extension necessary for their extraction. Before I 
adopted this plan I frequently got into scrapes ; 
when after the extraction of the placenta the mem- 
branes have been left behind, I have been sent for in 






152 ON LABOUR. 

twelve hours to the patient, who was said by the at- 
tendants to have something coming away. On in- 
troducing my finger, I have discovered fragments of 
the membranes, which I have piilled away : but they 
should have been removed before in the manner just 
described. I am sometimes called by young practi- 
tioners, perhaps six or eight hours ^after the birth of 
the child, to remove what I am toid is a retained pla- 
centa ; on making an examination, I find this mass 
at the top of the vagina, admitting an easy extraction 
by the funis, if pulled with sufficient firmness. Lec- 
turers, in stating that you must not pull at the umbi- 
lical cord as at the bell-rope, lest you should invert 
the uterus, have so intimidated beginners, that they 
have been afraid to use the necessary force. When 
the placenta can be felt at the upper part of the vagina 
by a common examination, you may pull with con- 
siderable force ; for the vagina being elastic, the pla- 
centa is so firmly retained that pretty much force is 
necessary to extract it. The danger in this case of 
inverting the uterus is not so great as that of separa- 
ting the cord from the placenta : but it will generally 
bear a considerable degree of extension. Should the 
cord be torn from the placenta, it is an evil : we lose 
our guide, and are deprived of the assistance of the 
cord in the extraction of the placenta. Therefore, 
whilst extracting by the cord, place the fore-finder 
of your other hand at the insertion of it ; and if you 
feel it give way, do not continue to extract by it, but 
pass up your hand, lay hold of the body of the pla- 
centa, and bring it away. A man must have the 
hand of a giant if it will not pass through the space 
which has just admitted the descent of the child. I 
wish to impress on your minds attention to the fol- 
lowing rule : — Do not separate the placenta from its 
attachment to the uterus, but remove it with as little 
force as possible when alreadij separated, and almost 
expelled by the action of the uterus. By acting thus, 






ON THE MANAGEMENT OF THE PLACENTA. 153 

you will in most cases prevent those perilous circum- 
stances which may attend the separation of the after- 
birth. But if you deviate from this rule you hazard 
two principal dangers : one, the inversion of the 
uterus ; the other, haemorrhage ; either of which may 
terminate in death. On passing your finger up the 
vagina after the birth of the child, you may feel 
nothing but the bare cord ; the placenta is then high 
up, and attached to the fundus uteri : if you now 
pull it away by force you will leave the mouths of 
the vessels of that part of the uterus open, to which 
the placenta was attached, and a frightful haemor- 
rhage will ensue : or you will invert the uterus. 
When the uterus is contracted you cannot invert it; 
but if it is flaccid and flabby, it is as easily inverted as 
the finger of a glove; and if while in this state you 
extract the placenta with force, you may cause the 
death of the patient. 

There are two circumstances which require a 
departure from the rule just mentioned; these are 
haemorrhage from the uterus, and the protracted re- 
tention of the placenta. 

Haemorrhage sometimes occurs after the birth of 
the child, but before the delivery of the placenta : 
you are, perhaps, waiting for pains to separate and 
expel it ; but instead of the placenta, blood comes 
away, and flows in such quantity that the patient 
soon begins to experience the symptoms of loss of 
blood ; she becomes pale and faint ; she has a singing 
in her ears, her vision is impaired, and the room ap- 
pears to be going round with her ; these symptoms 
imply great danger. In most instances there is no 
difficulty in detecting the haemorrhage ; the profuse 
discharge of blood externally, as w T ell as the symp- 
toms produced by its loss, are sufficiently obvious. 
But there is one case in which the haemorrhage may 
not be known, the condition of the patient may be 
mistaken, and consequently maltreated : the case 



154 0N LABOUR. 

alluded to is that of internal hcemorrhage, when the 
blood flows into the cavity of the uterus, and does 
not escape from its orifice. The constitution suffers 
from this haemorrhage as if an equal quantity of 
blood were discharged externally, and the effects are 
of course the same : the blood in either instance is 
out of the system of the circulation, and consequently 
the danger is equally great. I have seen many cases 
of internal haemorrhage. Not long since I was re- 
quested to attend at the examination of the body of 
a female who had died soon after delivery ; the labour 
appeared to "have terminated favourably, and the 
accoucheur had left her : soon afterwards she became 
pale and fainted : he was immediately sent for ; but 
just as he arrived she expired. There was no ex- 
ternal discharge of blood ; he knew not to what so 
fatal a change could be imputed. As soon as we 
entered the bed-room to examine the body, we per- 
ceived that the abdomen was much above the level 
of the body, and appeared as prominent as that of a 
woman seven months gone with child. The uterus, 
on its exposure, was seen to be enormously distended; 
and although there was no external evidence of 
haemorrhage, on cutting into it we found a mass 
(amounting to a gallon) of coagulated blood. The 
haemorrhage in this case occurred after the extraction 
of the placenta; but it most frequently happens 
when this body is lodged in the os uteri and upper 
part of the vagina, where it acts like a plug, by 
which the effused blood is confined within the cavity 
of the uterus. 

I was requested to attend a lady in her confine- 
ment who lived at a distance of twenty miles. As 
soon as she felt her first pain, a summons was sent 
to me, which I obeyed with obstetrical haste. When 
I entered the park, I saw a man beckoning the coach- 
man to drive faster : as we passed him he said some- 
thing, which I did not understand ; but the coach- 



ON THE MANAGEMENT OF THE PLACENTA. 155 

man, who was before, going at a furious rate, drove 
up to the door full gallop ; the footman who let me 
in was looking like a ghost, and the first words he 
uttered were, " My mistress is dead !" When I got 
into the hall, I saw servants running about in the 
utmost confusion ; up stairs the nurse was like a mad 
woman; and on entering the chamber of the lady, 
the old medical practitioner of the family, who had 
been in attendance from the commencement of the 
labour, was unable to speak : he was holding a candle 
in his hand, and pointing to the bed where the lady 
was lying ; her eyes were half open, her jaw hanging 
down, and the pulse was quite gone. I endeavoured 
to recover her by ammonia and brandy, pouring them 
literally down her throat ; but it was of no use — she 
was dead. As soon as the medical attendant had 
recovered his faculties, I received from him the fol- 
lowing narrative : — He had been sent for on the 
commencement of labour-pains, and the child was 
soon born • when the patient, being in high health 
and spirits, said it was the shortest and easiest labour 
she ever had, and was grateful for so quick a relief 
from her sufferings. In about ten minutes, I will 
not say what more he did, he pulled the funis, blood 
gushed forth, and he desisted ; after that there was 
very little external hemorrhage : but the maid ob~ 
served that the face of her mistress became pale, and 
her breathing quick ; she fainted, she recovered, 
looked about, talked incoherently, and again fainted ; 
again she recovered, but only to undergo the same 
change ; she fainted a third time, but did not recover; 
— for this they were waiting, doubtful whether it 
was a long fainting fit, or death. When the carriage 
arrived at the door it disturbed them : the lady had 
ceased to breathe three-quarters of an hour before 
my arrival. The placenta had not been extracted ; 
I introduced my finger, and found it resting over the 
os uteri at the top of the vagina : I turned it aside, 



156 ON LABOUR. 

and passed my hand into the uterus, and it went up 
beyond the umbilicus, through an immense mass of 
half-coagulated blood. There was no external hae- 
morrhage of any consequence : the catastrophe was, 
however, sufficiently explained by that which had 
taken place internally. 

How do you become aware that there is haemor- 
rhao-e ? It is in general indicated by external dis- 
charge, as well as by the constitutional symptoms 
described which ensue from the loss of blood. But 
when the haemorrhage is internal we are deprived 
of the former evidence, and can then draw this con- 
clusion only from the latter, or from the occurrence 
of symptoms which are produced by the loss of blood. 
Another evidence, not unworthy of atttention, may 
be obtained by placing your hand on the lower part 
of the abdomen ; when, instead of a hard, contracted 
ball, filling only the hypogastric region, the uterus 
will be felt to be soft and distended. This, in con- 
junction with the symptoms produced by loss of 
blood, constitute the signs of internal hsemorrhage. 
From ignorance of this kind of haemorrhage, very 
fatal mistakes sometimes occur. A woman soon after 
delivery faints ; there is no external discharge ; the 
practitioner supposes it to be common syncope, and 
resorts to cordials to relieve her; by such means he 
rouses the circulation, and again the haemorrhage is 
renewed internally; which is like giving brandy to 
a person who faints from venesection, and allowing 
the orifice in the vein to remain open. Nothing can 
be more absurd than the attempt to relieve fainting 
by stimulants, while the haemorrhage, on which it 
depends, is liable to be renewed as soon as the circu- 
lation is restored. 

In cases of retention of the after-birth, its situation 
in the uterus, and its relative circumstances, are not 
always the same. It is sometimes separated, but the 
uterus is not contracted, and consequently the orifices 



ON THE MANAGEMENT OF THE PLACENTA. 157 

of the vessels remain open. Sometimes the uterus 
contracts in the middle, forming what is called, from 
its figure, the hour-glass contraction, by which the 
cavity is divided into two chambers; and in the 
upper one, from which, perhaps, proceeds a con- 
siderable haemorrhage, is lodged the separated pla- 
centa. At other times part of the placenta is separa- 
ted, and a part still attached, which is owing to a 
firmer adhesion of one portion of it than of another to 
the uterus. A priori, when haemorrhage occurs, we 
cannot tell to which of these circumstances it is 
owing. When haemorrhage does take place, what 
are we to do ? The remedies are, first, the removal 
of the placenta; second, the application of pressure; 
third, the application of cold. When, after the 
birth of the child, and before the complete separation 
of the placenta, haemorrhage occurs, it is almost an 
invariable rule with practitioners immediately to ex- 
tract the placenta ; this is done on the supposition 
that the retained placenta prevents the contraction of 
the uterus. There are a few men who doubt the 
propriety of this treatment, alleging that, as the 
haemorrhage is occasioned by a partial separation of 
the placenta, produced perhaps by pulling the funis, 
the advantage of laying open ten or fifteen additional 
orifices of blood-vessels must be very questionable. 
My advice on the subject is this ; supposing the child 
born, and the placenta not come away, and blood 
begins to flow from the vagina, make an examination, 
and in many cases you will find the placenta resting 
on the os uteri, at the upper part of the vagina ; here 
there can be no objection to removing it, for it is 
separated and partly expelled ; and often when re- 
moved all haemorrhage ceases. But suppose, on 
passing up your finger, you cannot feel the body of 
the placenta ; it is then still high up, and adhering 
to the uterus. In this case, as the first step, I should 
doubt the propriety of its removal. The first object 

21 



158 ON LABOUR. 

here is to induce the contraction of the uterus, and 
the second is to remove the placenta : it is wrong to 
invert the process, by first removing the placenta, and 
then exciting the uterus to contract. If in a common 
examination you can feel the body of the placenta at 
the upper part of the vagina, remove it; but if you 
cannot in this way discover it, you have reason to 
believe that it is still attached to the fundus uteri, or 
elsewhere ; in this case, first employ the means to 
produce the contraction of the uterus, and then re- 
move the placenta. Styptics and astringents have 
been employed to induce contraction of the muscular 
fibres of the uterus ; an old woman would use alum, 
and give vitriolic acid; but the uterus is most effect- 
ually stimulated to contract by pressure and cold. 
If, as soon as the child is born, you press and rub the 
hypogastrium, the action of the uterus will be excited, 
and, generally, you will perceive the commencement 
of the contraction, by its hardening and diminishing 
under your hand. Should it be necessary, you may 
also introduce your hand into the cavity of the uterus; 
this is one of the most effectual means of inducing 
the uterus to contract, whether before or after the de- 
tachment of the placenta. With respect to the best 
mode of applying pressure, it is to be remembered 
that the blood does not flow from the whole surface 
of the uterus, but from that part only to which the 
placenta adhered. The extent of the bleeding sur- 
face corresponds with that of the placenta which was 
attached to it, and is about a span in diameter; but 
after the birth of the child, this surface is somewhat 
diminished, and may be covered with the fist, if it 
could be directed to the exact place with precision. 
Pass your hand into the uterus, and press with it 
against the bleeding surface, and with the open hand 
on the outside of the abdomen make counter-resist- 
ance to the fist on the inside ; in this way you can 
make pressure on almost any part of the uterus. I 



ON THE MANAGEMENT OF THE PLACENTA. 159 

have known the most profuse haemorrhage thus sup- 
pressed. But how are you to ascertain at what part 
of the uterus the placenta was attached ? There are 
two general circumstances which will assist you, 
though they are not infallible. The placenta is most 
commonly attached to the fundus uteri; and the 
chances are ten to one, if we compress that part, that 
we shall include a very considerable portion of the 
bleeding surface. But do not depend on this proba- 
bility entirely ; observe also, before the detachment 
of the placenta, which way the cord leads, whether 
to the front, sides, back, or fundus of the uterus. By 
attention to these particulars, you may generally know 
where the placenta is attached; and as you would 
place your finger on the orifice of a spouting vessel, 
so introduce your hand, and with your closed fist 
within, opposed by the other hand on the outside, 
compress this bleeding surface. 

There are many cases in which flooding begins 
immediately after the birth of the child. I was re- 
quested by a lady, who was accustomed to have 
profuse flooding immediately after the birth of the 
child, to attend her at her next confinement. The 
membranes were ruptured before I arrived ; her face 
was much flushed ; her pulse full and rapid. What 
was the cause of this disturbed state of the circula- 
tion? Did it proceed from the apprehension of 
danger, or was it from her having taken three glasses 
of wine daily after dinner, and a pint of porter at 
supper, fearing she should want strength during her 
labour? Be this as it may, she fell into labour with 
a disturbed state of the circulation ; -and the child 
was born soon after my arrival. I secured the navel 
string, and gave the child to the nurse ; but, being 
prepared for haemorrhage, I determined not to inter- 
fere with the placenta until it was separated. With 
one hand I used friction on the abdomen ; and with 
the other under the clothes, felt if there was any 



160 ON LABOUR, 

haemorrhage. In five minutes, she said there was a 
quantity of something coming away, and gush came 
the blood from the vagina : I passed up my finger, 
and found the placenta separated and forced a little 
way into the vagina ; and by a gentle extension of 
the cord I extracted it, when the haemorrhage im- 
mediately ceased. I now thought all flooding was 
over, but it soon began again ; her pulse sunk, and 
she fainted. A short time before this case occurred, 
Mr. Rigby, in a conversation with me on this subject, 
had expressed a favourable opinion of plugging the 
vagina with cloths dipped in vinegar, as recommended 
by Le Roux, remarking that the lives of many had 
been saved by it ; but I feared, as the uterus is large 
at this time, that blood would still flow into it, the 
escape of which being prevented by the plugging of 
the vagina, the case would merely be converted into 
one of internal haemorrhage. However, I determined 
to give this mode of treatment a trial in the present 
instance ; and therefore called for large pieces of 
linen, which, being first dipped in vinegar, I pushed 
one by one up the vagina almost into the uterus. 
The hemorrhage seemed to cease; the patient re- 
covered from her syncope ; and I again thought all 
danger was over. She had afterwards a few trifling 
pains : the belly began to swell, and again she faint- 
ed ; but gradually so far recovered as to express a 
wish to see her husband and children before she 
died ; and I expected she would have died : her 
mouth was drawn on one side, and she became con- 
vulsed. I would have given anything for a consul- 
tation, but in these cases there is no time for it ; the 
life of the patient depends on the man who is on the 
spot : he must stand to his gun, and trust to his own 
resources. A practitioner who is not fully competent 
to undertake the management of these cases of 
haBmorrhage, can never conscientiously cross the 
threshold of a lying-in room. I immediately pulled 



ON THE MANAGEMENT OF THE PLACENTA. 161 

away the plugs from the vagina, and introduced my 
hand into the uterus, through a quantity of half- 
coagulated blood, up to the fundus, where, inclining 
towards the front of the uterus, I felt something 
ragged projecting from the surface : to this part I 
applied my fist, and made counter-pressure with my 
hand externally. The haemorrhage ceased, and no 
more blood came away. In two or three minutes 
the uterus began to contract, and I found my hand 
pushed gradually lower and lower, until expelled by 
the complete contraction of the uterus. I then with- 
drew my hand from the vagina, and the haemorrhage 
did not recur. A few minutes elapsed, when she 
opened her eyes, and asked if all danger was over. 
I replied she was much better, and directed her to 
remain quiet. The effect of the stimulus of my hand, 
or of its pressure against the parietes of the uterus, 
was instantaneous ; and in three days she was so 
much recovered that she appeared to suffer nothing 
from the loss of blood. The best method then at 
once of making pressure on the bleeding vessels, and 
of exciting the contraction of the uterus, is to intro- 
duce the hand into the uterus, and applying the fist 
firmly to that portion of its surface over which the 
placenta was attached, make on the outside a counter- 
resistance with the other hand : this is much more 
effectual than friction on the abdomen, or tickling 
the uterus internally with your finger. 

The employment of cold is very generally resorted 
to for the suppression of uterine haemorrhage. This 
remedy may be applied by means of cloths dipped 
in vinegar and passed into the vagina, or laid over 
the abdomen — by introducing ice into the vagina — 
by covering the abdomen with snow — by injecting 
cold water up the rectum, &c. Ice and snow are 
very good remedies ; but cases of uterine haemor- 
rhage occur in the summer as well as in winter, and 
there are perhaps no ice-houses at hand. The best 



162 0N LABOUR. 

method of applying cold is that which can be resorted 
to whenever it may be required, alike at all seasons 
of the year. Cold applied with a shock is more 
likely to produce a contraction of the uterus than any 
other mode of its employment. A case occurred to 
me in which haemorrhage came on soon after the 
expulsion of the placenta. I covered the abdomen 
with ice ; but the belly, then flaccid, began to be 
distended, and constitutional symptoms ensued from 
the loss of blood. I swept off all the ice from the 
abdomen ; and the patient being, with the exception 
of the pubes, entirely uncovered, I took an ewer full 
of cold water, made still colder by the addition of 
two handfuls of salt, and holding it aloft over her, let 
it fall, cold and heavy, on the exposed abdomen. 
The effect was immediate ; the uterus began to con- 
tract like a ball above the pubes : but soon afterwards 
it became flaccid again ; and again this water-fall 
immediately induced it to contract ; and the action 
of it was kept up until the uterus was fully contracted. 
Of the value of this remedy I can speak with confi- 
dence, from an experience of it in many cases. The 
application of cold with a shock is much more effectual 
in these cases than any other mode of employing 
it. The injection of four ounces of cold water into 
the uterus by means of a syringe, or elastic gum 
bottle, with an ivory pipe or flexible tube attached, 
of sufficient length, is also a good remedy in these 
cases of uterine haemorrhage. The pipe should be 
introduced into the cavity of the uterus, and the 
water propelled quite up to the fundus. The best 
methods, then, of using cold for the purpose of stimu- 
lating the uterus to contract, are — first, by a shock, 
as when water is poured from an height upon the 
abdomen ; and, second, by the injection of water into 
the cavity of the uterus. Let it never be forgotten, 
in urgent cases of uterine haemorrhage, that the most 
powerful remedies are pressure and cold. Some- 



ON THE MANAGEMENT OF THE PLACENTA. 163 

times the haemorrhage is so moderate, and so readily 
checked, that nothing more is required than to apply 
cloths dipped in vinegar or water to the abdomen ; 
but this, in extreme cases, is by no means to be 
depended upon. 

The removal of the placenta is, in the practice of 
midwifery, a matter of so much importance, that I 
feel it necessary to enlarge on the subject ; and in 
so doing I shall be guilty of some repetitions, for 
which I hope the design of rendering my instruction 
as complete as possible, will prove a sufficient apology. 
How will you remove the placenta ? There are two 
modes of accomplishing its removal ; one by pulling 
at the timbilical cord, the other by passing up the 
hand into the uterus ; which of these is to be pre- 
ferred, will depend on the situation of the placenta. 
If it is separated, and lying over the orifice of the 
uterus, and can be felt at the upper part of the vagina, 
there is no necessity for introducing your hand to 
remove it ; for after a moderate time you may with- 
draw it by pulling the cord. But suppose the blood 
is rushing from the vagina, and on making an ex- 
amination, the placenta is ascertained to be high up 
beyond the reach of the finger, you cannot then tell 
where it is attached, but most probably to the fundus : 
here if you attempt to pull it away by the cord, you 
might invert the uterus, or break the cord ; or if you 
detach the placenta you might leave the uterus 
dilated, and the mischief you occasion may be of a 
fatal kind. Never pull by the cord when the placenta 
is high up. Pass your hand through the vagina into 
the uterus, and place the other hand externally on 
the abdomen, to steady the uterus and prevent its 
receding. You may find the uterus in one of two 
different states relatively to the placenta. The uterus 
may be contracted in the middle, forming the hour- 
glass contraction, and the placenta may be imprisoned 
in the upper chamber ; or this contraction may not 



164 ON LABOUR. 

have occurred, and the placenta may be found ad- 
hering to a large surface of the uterus. If the pla- 
centa is retained by the hour-glass contraction, pass 
your fingers along the cord through the inferior por- 
tion of the uterus, and they will arrive at a round 
hole through which the funis passes. You cannot 
now feel the placenta, and the first time you meet 
with a case of this kind, you might mistake this 
opening for a laceration of the uterus, and suppose 
that the placenta has escaped into the cavity of the 
peritonaeum ; but the circular hole is formed by the 
irregular contraction of the uterus, and leads to the 
upper cavity, or chamber as I call it, in which the 
placenta is confined. This circular hole you must 
dilate — steady the uterus externally with one hand, 
and forming the fingers of the other into a cone, pass 
them through this orifice gently, but perse veringly. 
It is by pressure and perseverance, not by violence, 
that we pass our hand through this contracted ring 
into the upper chamber where we are to grasp the 
placenta ; but let it never be forgotten, that though 
it is commonly said the hand is introduced into the 
uterus to extract the placenta, yet it is for a two-fold 
purpose, partly to extract the placenta, hut mainly to 
produce contraction of the uterus. As soon as the 
hand is fairly passed through this contracted portion 
into the upper chamber, press with your knuckles 
gently against the uterus, and excite it to thrust out 
both your hand and placenta. Do not, as soon as 
you have grasped the placenta, withdraw it, and leave 
the upper cavity dilated, but compress the uterus 
between the hand which is within its cavity, and 
that which is placed on the outside of the abdomen. 
If it is not thus excited to contract, I make the nurse 
throw an ewer full of cold water on the patient's 
belly ; and if she will not do this, I do it myself. 
The uterus then immediately contracts, and forces 
my hand and the placenta into the vagina ; and with- 



ON THE MANAGEMENT OF THE PLACENTA. 165 

drawing them from thence, I have accomplished two 
objects, namely, the contraction of the uterus, and 
the removal of the placenta. Some practitioners 
think when haemorrhage occurs before the placenta 
is expelled, that they have nothing to do but to claw 
it away : and having thus dragged it out of the nterus, 
that they have employed the most effectual remedy 
for uterine haemorrhage. 

Suppose, on introducing your hand, you do not find 
this hour-glass contraction, but that the placenta is 
retained by extensive adhesions ; in this case I ques- 
tion the propriety of its immediate removal; the 
placenta is still adhering in part, and the uterus is 
large and uncontracted. It is, I conceive, a very 
singular remedy in cases of haemorrhage, to pluck 
away the adhering portion of the placenta, by which 
an additional number of bleeding vessels are laid 
open, while the uterus, being still dilated, there is 
nothing to restrain a proportionate increase of 
haemorrhage. First stimulate the uterus to contract 
by the introduction of the hand by pressure, and by 
the application of cold ; excite the action of the 
uterus by the pressure of your fist against its sides 
or fundus ; compress the uterus where the placenta 
is partially separated, and you will certainly diminish 
the extent of the bleeding surface. If these means 
fail to produce the necessary contraction, apply cold 
with a shock. You may sometimes succeed in the 
latter design, by merely immersing your hand in 
cold water, and suddenly placing it on the abdomen. 
If this is insufficient, you must have recourse to a 
fall of water from an height on the abdomen, or to 
the injection of cold water into the uterus in the way 
before described. This is the best treatment in cases 
of this description ; it is exceedingly unsafe to invert 
this order, by first extracting the placenta, and then 
inducing the uterus to contract. Generally, by 
pressing, splashing, or injecting, you will produce 

22 



166 ON LABOUR. 

both the contraction of the uterus, and the expulsion 
of the placenta. 

Cases sometimes occur in which a moderate con- 
traction of the uterus will not prove sufficient to 
separate the placenta, it will then become your duty 
to do it ; and there are two modes of accomplishing 
this separation. Dr. Hamilton says it is sufficient, 
in general, without insinuating the fingers between 
the edge of the placenta and uterus, to pass your 
hand along the cord, and on arriving at the placenta 
to expand your fingers to its edges ; the placenta is 
then grasped, and by bringing your fingers together 
it is pressed from the circumference to the centre, 
and in this way detached from the uterus. This is 
a very good method. The common proceeding is to 
insinuate the fingers between the placenta and the 
surface of the uterus, and thus peel it off until the 
whole is separated. But this, as it is usually de- 
scribed, is a bungling affair. The directions are, you 
must introduce your fingers along the cord, till you 
arrive at the placenta, and then pass them to the 
edge of the placenta, and peel it off by insinuating 
your fingers between it and the uterus ; but you are 
to recollect that, by acting thus, the hand and fingers 
are within the membranes of the ovum, and the young 
practitioner will be baffled in his attempt to get his 
ringers between the uterus and placenta. The best 
method of avoiding the membranes is to withdraw 
the hand to the cervix uteri and feel for the bare 
uterus : pass your fingers along its surface to the 
placenta, when your fingers will be on the outside of 
the membranes, which will render the accomplish- 
ment of your object comparatively easy. Having 
detached the placenta, you compress the uterus, and 
excite its action with your fist, and allow its con- 
traction to expel both your hand and the placenta. 
Remember, when the hand is introduced to separate 
and remove the placenta, that you have two objects 



ON THE MANAGEMENT OF THE PLACENTA. 167 

in view, and if the hand, with the placenta, is with- 
drawn hefore the uterus is contracted, you only com- 
plete one half of your duty. 

Another method of treating uterine hemorrhage is 
the following : — Take linen cloths saturated with 
vinegar, and pass them up the vagina one by one, 
and not only fill the vagina, but also half fill the 
cavity of the uterus. This acts in two ways : the 
uterus is corked up, and the effused blood coagulates, 
and the stimulus of the vinegar excites the uterus to 
contract; this kind of plugging owes its chief effi- 
cacy to the vinegar. Mr. Rigby considers this a 
valuable morsel of knowledge : he thinks it by far 
the most effectual means of suppressing uterine 
hemorrhage, and he relates many well described 
cases in support of its efficacy, which he believes 
would have terminated fatally had it not been for 
this remedy. I do not like it so well as compressing 
the bleeding vessels with my fist ; and one of the best 
arguments against it is, that there is such a thing as 
internal haemorrhage. As the uterus is now very 
large, an immense quantity of blood may still be 
poured into its cavity notwithstanding the plugging 
of the vagina and lower portion of the uterus. For 
this reason I employ this remedy with rather a faith- 
less hand. But if it is resorted to, means should be 
used to prevent the dilatation of the uterus; this is 
to be done by pressure externally with your hand, 
or with napkins folded and placed on the abdo- 
men, making a pile of compresses,' which are to be 
bound down by a bandage placed over them and 
carried round the body ; with this precaution, they 
say, you may safely trust to the vinegar plug. I 
have recommended three remedies for the treatment 
of uterine hemorrhage. These are the removal of 
the placenta when detached, pressure, and cold. In 
addition to these, I think it a promising expedient to 
take a- sponge dipped in vinegar, and carrying it up 



168 ON LABOUR. 

through the uterus, apply it to its fundus. I fear 
nothing so much as haemorrhage, which in five or 
ten minutes may occasion death, and should there- 
fore not hesitate to dab the fundus uteri with vinegar. 
So many trifling remedies are recommended in these 
cases, that lives are often lost by postponing to them 
the employment of more powerful ones. Thus much 
for the suppression of uterine haemorrhage. Next 
of the treatment of its effects upon the constitution. 

Syncope is the common consequence of a profuse 
loss of blood. Some practitioners consider the oc- 
currence of syncope an advantage, inasmuch as the 
circulation is, during this state, reduced very low, 
and the haemorrhage is in consequence restrained. 
Others consider the syncope itself a state of danger. 
These opposite views lead to equally opposite treat- 
ments ; those who consider syncope an effort of nature 
to restrain haemorrhage, are fearful of giving stimu- 
lants by which the circulation will be excited, and 
the haemorrhage renewed ; those who fear the state 
of syncope itself, give stimulants to avert that which 
they regard as the most formidable danger. More- 
over, it is alleged by those who do not consider 
syncope a salutary effort, that the uterus does not 
contract during its continuance. I believe myself 
the best remedy for syncope is that which most effec- 
tually restrains haemorrhage ; and consequently the 
best treatment is that which will induce the con- 
traction of the uterus. It is certainly true that the 
uterus during syncope contracts but feebly ; yet I 
can positively assert from experience that it will 
contract during this state. Upon the occurrence 
then of syncope, I should still direct my efforts to 
producing contraction of the uterus, which I should 
endeavour to excite by the pressure of my hand 
against its fundus in the manner before described, 
by the injection of cold water into the uterus, or by 
the external application of cold with a shock. If the 



ON THE MANAGEMENT OF THE PLACENTA. 169 

syncope was not long continued, or if the circulation 
was resumed with a distinct though rather languid 
pulse between each fit, I should, in this moderate 
kind of syncope, be very cautious in administering a 
stimulus, or if I gave any, it should be perhaps only 
a glass of cold water. If in this state of things I 
succeeded in producing a contraction of the uterus, 
I should not fear the effects upon the constitution of 
this degree of syncopetic affection. But if the haemor- 
rhage is at once so sudden and profuse as to endanger 
life, if the syncope is protracted ; if a pulse, however 
feeble, cannot be felt at the wrist ; if there is in con- 
nection with this state of the circulation disordered 
respiration, convulsive action of the larynx, or vomit- 
ing, then the state is truly an alarming one, and, in 
addition to the use of the most powerful means to 
excite the contraction of the uterus, calls for the 
vigorous employment of remedies which are cal- 
culated to restore the circulation. The stimuli em- 
ployed on occasions of this kind are brandy, ammonia, 
and laudanum. Under a state of syncope of the 
kind just described, you may give equal parts of 
brandy and water, frequently repeated : you may 
give large doses of ammonia in water ; you may give 
laudanum in brandy and water. The stimulus of 
brandy is not the best of these, being liable to the 
objection that a greater degree of fever is afterwards 
produced by it than by the others. Ammonia excites 
the organs of circulation, but tends less to produce 
subsequent fever. But of all the remedies for the 
relief of the most alarming symptoms which ensue 
from loss of blood, laudanum is the best. Dr. Hamil- 
ton of Edinburg, whose judgment in this department 
of practice is equal to his great experience, in a case 
of the kind here alluded to, would recommend even 
a hundred drops of laudanum, or, if this is rejected 
by vomiting, five grains of opium in powder with 
aromatic confection. All these means of restoring 



170 ° N LABOUR. 

the circulation require to be repeated as often as may 
be indicated by the degree of their success, or by the 
state of the patient. The circulation being fairly 
restored, the same remedies should be given at longer 
intervals, and in lesser doses, to sustain the circula- 
tion, which may otherwise again fail. If you with- 
draw opium suddenly, the constitution may as 
suddenly sink : therefore withdraw it gradually by 
diminishing the dose, and the frequency of admin- 
istering it. After the circulation is again fairly 
established, much care and attention will still be 
required to preserve its proper equilibrium, lest 
violent reaction should take place in any important 
organ ; for this reason an unstimulating diet must 
now be enjoined, and aperients directed as occasion 
may require. 

It sometimes happens that without the accompani- 
ment of haemorrhage, there is merely a retention of 
the placenta, which may be situated high up and 
firmly attached to the uterus ; here you must en- 
deavour to excite the contraction of the uterus, by 
rubbing and pressing the belly ; if it produces pain, so 
much the better, as this is the indication of an action 
of the uterus by which the placenta may be separated. 
But suppose your efforts are not successful, what next 
are you to do ? there is then no remedy but to intro- 
duce the hand and bring away the placenta. How 
soon, and in what manner, is this to be done ? If 
there is no haemorrhage, the longer you wait the 
better ; the placenta is never so safely expelled as by 
the efforts of the uterus : for when it is clawed from 
the surface of the uterus, there is generally a piece, 
or shreds of it left behind, which will undergo putre- 
faction, occasion a highly offensive discharge, per- 
haps irritative fever, and even death. I would re- 
commend you to wait at least two hours after the 
birth of the child ; if you wait four, so much the 
better, and at frequent intervals during this time use 



ON THE MANAGEMENT OF THE PLACENTA. 171 

pressure and friction on the abdomen. If after 
" waiting this time the placenta is not expelled, you 
' must pass up your hand and separate it ; you may 
find it either simply attached to the uterus, or im- 
prisoned by the hour-glass contraction, with or with- 
out an attachment to the uterus. In either case sepa- 
rate and extract it in the manner formerly directed. 
It is dangerous to leave the placenta very long in 
the uterus. There is a practitioner in this town, of 
very extensive practice, who says that haemorrhage 
is always produced by attempts to separate and ex- 
tract the placenta ; he, therefore, sometimes leaves it 
for days in the uterus ; and I have seen in one week 
*two deaths from his adherence to this practice. One 
of the patients alluded to, when I first saw her, had 
a face like wax, a hurried respiration, with a rapid, 
thready pulse : she had been delivered three days, 
and the placenta had not been removed. I asked her 
medical attendant where it was ? is it detached ? He 
replied, I know not. When did you examine ? Last 
night I made an examination, and found the placenta 
in the vagina. " I took it away ; it stunk worse than 
any of your macerating tubs : the patient died in a 
few days from symptoms of irritative fever produced 
by the presence of this putrid mass. During the 
three days which intervened between her delivery 
and my visit, she had repeated attacks of haemorrhage, 
which had thus blanched her face. The face, in- 
deed, in these cases, is usually pale, except during 
the exacerbations of fever, when it has a hectic flush. 
In the other case, I found the placenta lying within 
the orifice of the uterus : this patient also died with 
similar symptoms. Nothing had been done but to 
apply vinegar cloths to the pudenda. This treat- 
ment some practitioners think the ultimatum of our 
art ; and when the patient dies, they say very gravely, 
screwing up their mouths, that everything was done 
that could be done, and thus they console themselves 



172 ON LABOUR. 

for their ignorance. This treatment amounts to 
nothing ; if the placenta is retained longer than two, 
three, or four hours, and you cannot, by friction, pres- 
sure, &c, on the abdomen, excite the uterus to expel 
it, you must introduce your hand into the uterus and 
bring it away, in the manner before described ; 
and until this is done you must not leave your 
patient. 



ON DIFFICULT LABOUR. 173 



LECTURE THE FOURTH. 



ON DIFFICULT LABOUR. 



If the practice of midwifery be an art, it consists, 
not in the treatment of a natural labour, in which we 
have nothing to do but to look on and beguile the 
time until it is over ; but it is in conducting the 
patient safely through those deviations from the 
natural process which every now and then occur. 
These deviations may be arranged under three 
heads : — 

1. Impeded Labour. 

2. Unnatural Presentations. 

3. Complicated Labour. 



23 



174 ON DIFFICULT LABOUR, 



Section I. — On Impeded Labour. 



In impeded labour the position of the child is 
supposed to be natural, but there is on some other 
account unusual difficulty in its passage through the 
pelvis. The difficulty or facility with which a body 
passes through any orifice or canal, depends on three 
circumstances. First, the propelling power. Se- 
cond, the size of the aperture. Third, the size of the 
body propelled, relatively to the opening through 
which it has to pass. Applying this general rule to 
the process of labour, first, if the uterus, the propel- 
ling power, is either weak or irregular in its mode 
of action ; or, second, if the aperture, whether of the 
pelvis, os uteri, or of the canal of the vagina, is con- 
tracted ; or, third, if the head of the child is unusually 
large — either of these circumstances will retard the 
progress of labour, and to one or more of them is 
to be referred every variety of tedious or impeded 
labour. 

An inadequate exertion of the uterus may be 
owing either to fever, not of the idiopathic kind, bat 
rather a hurried circulation, hot skin, &c. ; to mental 
emotion, as fear, for example, or to debility. 

A febrile state of the system sometimes precedes 
and accompanies labour, rendering the action of the 
uterus sluggish or inefficient, The objects of treat- 
ment in this case are to cool the skin, and to tran- 
quillize the circulation : the patient should be kept 
quiet in bed ; her diet should consist of gruel, tea, 



IMPEDED LABOUR. 175 

barley water, &c, and her mind should be kept free 
from disturbance; the bowels should be cleared by 
an aperient medicine ; and if these means are not 
sufficient, a few ounces of blood should be taken from 
the arm. If you can relieve the heat of the skin, 
and tranquillize the circulation, the uterus will exert 
itself, and the labour will proceed in the customary 
manner. 

. Depressing emotions of the mind have consider- 
able influence on the actions of the uterus ; even the 
sight of the accoucheur, more especially if he is a 
stranger, or if his manners are not agreeable, may 
suspend the action of the uterus for perhaps half an 
hour. A lady whom I attended, owing to an appre- 
hension that she should die if she became pregnant, 
was persuaded, with great difficulty, to marry.* Her 
mind was still so impressed with this fear, that not- 
withstanding all the encouragement I could give, it 
had the effect of protracting her labour to the°period 
of thirty-six hours. Since the death of the Princess 
Charlotte* I have had many opportunities of observ- 
ing the same effect from a similar apprehension. In 
this state of mind we must keep up the spirits of our 
patient, both during her pregnancy, and at the time 
of labour, by anecdotes of the most favourable ac- 
couchements of those who have entertained equal 
apprehension, and by every species of encouragement 
in our power. 

Constitutional debility, in which the uterus parti- 
cipates, is one of the most frequent causes of pro- 
tracted labour. The class of females to which I par- 
ticularly allude, are those subject to fainting fits, 
hysteria, and all the tribe of nervous affections. Often 
have I been detained many hours, when, if the uterus 
had acted with vigour, a few pains would have ex- 

* This event occurred a few months before the delivery of these 
lectures. 



-. ^g ON DIFFICULT LABOUR. 

pelled the child. Those who have a languid circu- 
lation, and a weak constitution, are benefitted by 
cordials and good nourishment ; you may give half 
a glass of wine, once in two or three hours, which 
will invigorate the system, and render the action of 
the uterus more powerful. Debility of the muscular 
system, in which the uterus participates, is some- 
times the effect of disease. A sentimental young 
man fell in love with a young lady of a sickly habit, 
who was as pale as a corpse, and had, as the doctors 
thought, tabes mesenterica ; and this sentimental 
young man and sickly young lady were married. 
All their friends cried shame, and said surely she 
never will become pregnant; she however did be- 
come pregnant, and I attended her in her confine- 
ment. It was a breech presentation ; I cheered her 
up, and supported her with nourishment, and occa- 
sionally with wine. The labour was extremely 
tedious, but as the breech descended, I was enabled 
to render considerable assistance by passing my 
fingers into the groins of the- child, and she did well 
in spite of her pale face and languid circulation. 
Always in breech presentations acquaint the family 
that everything is right as it regards the mother, 
but that the position of the child is such as to en- 
danger its life. Thus your reputation is safe if the 
child is dead, and you gain credit if it is born 
alive. 

An irregular action of the uterus is a very com- 
mon cause of protracted labour. The child is said 
to be expelled by the pains, in the common language 
of midwifery ; but it is by the contraction of the 
uterus attended with pain, and this so constantly, 
that the term " pain" is used to denote the contrac- 
tion also which is its accompaniment. But it some- 
times happens that the pains are frequent and in- 
tolerable; yet they produce no effect on the child, 
and the os uteri does not become dilated. When the 



IMPEDED LABOUR. 177 

uterus acts in a regular and efficient manner, at the 
time of a pain you feel its orifice enlarged, and the 
distended membranes pressed against it ; bat in those 
which are called false or spurious pains the os uteri 
is not dilated, and the distended membranes are not 
pressed against it. In this case the edge of the os 
uteri is so far from being rigid, that when the liquor 
amnii has escaped, and the bald head presents, you 
may slip the os uteri up a considerable way over it ; 
still the pains are not attended with contraction of 
the uterus, or else the uterus contracts in an im- 
proper direction, so that there is no expulsive action 
on the child, and no dilatation of the os tincse. What 
are you to do ? They tell you that these are spurious 
pains, which will cease under the exhibition of opium. 
I wish this remedy could be depended on ; but I 
have given opium in one, two, and three grain doses, 
and it has often failed ; it occasions headache and a 
sick stomach ; it relieves the pains in a slight degree ; 
but they will still be sufficient to keep the patient 
awake and miserable, and you had better not resort 
to it. An old practitioner told me he often relieved 
these spurious pains by a laxative dose of sulphate of 
magnesia, followed by twenty drops of the tincture 
of hyosciamus every three or four hours. I am tired 
of giving opium in these cases ; my remedy is tinc- 
ture of time, the loss of which is the only thing to 
be regretted, for it at least produces no additional 
evils. You must keep up the spirits and confidence 
of the patient and her friends : a female companion 
who has herself had half a dozen tight labours, and 
who can tell stories of friends who have been a week 
in labour, and have done very well at last, will be a 
good assistant to you. 

The uterus will sometimes be stimulated to con- 
tract by rupturing the membranes, or by an injection 
of salt and water up the rectum ; but either expedient 
must be employed with caution. Never rupture 



178 ON DIFFICULT LABOUR. 

the membranes until the os uteri is almost or entirely 
dilated; if this is done prematurely, you lose the 
benefit of their distending force in the dilatation of 
the os uteri, and the labour will be greatly retarded. 
But when the os uteri is fully dilated, and the pains 
ineffectual, you may rupture the membranes and let 
out the liquor amnii ; the head of the child taking 
their place, will often stimulate the uterus to act with 
more vigour. I have frequently, in these cases, 
thrown up into the rectum an injection composed of 
two table spoonfuls of salt, with eight or ten ounces 
of warm water and a little olive oil ; this is often fol- 
lowed by a speedy and more vigorous action of the 
uterus ; and if the uterus again acts languidly, I 
repeat this injection, from which I never saw any ill 
effects, every two hours. 

The Americans recommend the ergot of rye, in 
doses of half a drachm or two scruples, and affirm 
that the uterus is almost immediately excited by it 
to a vigorous action. I never used it, neither do I 
credit what has been said respecting its efficacy.* 

A narrow or contracted state of the soft parts is 
another of the causes enumerated of impeded labour. 
If, at the commencement of labour, you make an 
examination, you will find that the vagina is separated 
from the cavity of the uterus by the portion called 
its cervix, in the centre of which you will perceive 
a small circular orifice termed the os uteri ; and 
until this circular aperture is fully dilated the child 
cannot be born. The dilatation of this aperture is so 

* 1 have had many opportunities of putting this remedy fairly 
to the test, by administering it in cases, the tediousness of which 
I had been led to anticipate, by my attendance on the same women 
in former labours, which were exceedingly protracted from a 
sluggish and ineffectual action of the uterus. I have repeatedly 
given the ergot in half drachm and two scruple doses ; I have 
given it both in powder and in infusion ; and I never witnessed 
in any one instance the slightest benefit from it. — Editor. 



IMPEDED LABOUR. 179 

slow a process, that it generally occupies two-thirds 
of the duration of labour. In a first labour the os 
uteri dilates slowly, but more quickly in a young 
girl of eighteen or twenty, who is healthy and vigor- 
ous, than in women at a more advanced period of 
life. In women of forty years of age or more, if they 
have never before had a child, the process of dilata- 
tion is very tardy, the os uteri is often, though not 
constantly, found rigid and dry. In some cases the 
slow dilatation of the os uteri is owing to a state of 
disease. The cervical portion of the uterus is some- 
times thick, hard, gristly, hot, and painful, as if in a 
state of subacute inflammation ; here the dilatation 
proceeds very slowly, and the os uteri, to the touch, 
instead of conveying the sensation of an orifice in a 
piece of broad-cloth, feels like an orifice in an inch 
deal-board. In slight cases of this kind, the warm 
salt and water injections before mentioned are of 
great service, relieving, as by a fomentation, the 
sub-inflammatory state of the cervix uteri : but when 
this peculiar state of the parts exists in a greater 
degree, bleeding is a still better remedy ; for this 
rigidity is not owing to a deposition, as is proved by 
the relaxation produced- by syncope. When, there- 
fore, the labour is long retarded from this cause, I ad- 
vise you to take away about fourteen ounces of blood ; 
if the patient faints, do not be in a hurry to recover 
her, but rather support her for a few minutes in the 
upright posture. The pains during the faintness 
cease, and the labour is at a stand ; but as soon as 
the syncope is over, the orifice, which before was 
rigid and dry, becomes lubricated and relaxed. 

There is another state of the os uteri which renders 
its dilatation tedious ; instead of being preternaturally 
hard, it is soft, flabby and cedematous. This state 
is generally induced by an early rupture of the 
membranes, owing to which the cervical portion of 
the uterus is compressed between the head of the 



180 ON DIFFICULT LABOUR. 

child and the pubes ; and the return of the fluids 
being obstructed, the os uteri becomes thickened, 
and its dilatation is in consequence extremely slow. 
The best remedy in such a case is patience; the 
dilatation though in general very tedious, is however 
sometimes accomplished in a few minutes. I at- 
tended a lady whose former labours had been very 
quick ; on my arrival I found the pains were strong, 
and though the os uteri was only dilated to the size 
of half a crown, I, like a simpleton, patted her on 
the shoulder, and told her to keep up her spirits, for 
the child would soon be born. A man must be a 
goose under such circumstances to give such a 
prognosis ; for he knows not when the labour will 
be over ; and if his prognosis is not verified he loses 
credit. Hour after hour passed, and the pains con- 
tinued, but the os uteri was not more dilated, the 
labour-pains became still more rapid and violent; 
she complained also of a constant pain near the 
symphysis pubes, and I feared a laceration of the 
uterus would take place. I bled her to the amount 
of fourteen ounces ; she fainted ; I kept her in an 
upright posture in order that the syncope might 
produce its full effect ; the- pains were suspended 
for about half an hour, when they returned, and her 
cheeks resumed their natural colour. I examined, 
but found the bleeding had done no good. I then 
applied two fingers against the edge of the os uteri 
next the symphysis pubes, and pushed it up at the 
time of a pain, and kept it up after the pain was 
gone off : at the next pain I pressed the os uteri still 
higher, and repeated the same proceeding at about a 
dozen pains, when the os uteri slipped quite over 
the head of the child and the labour was soon over. 
In the thick, spongy, and cedematous state of the 
os uteri this plan answers very well ; I have found 
it succeed in many cases, and there is no occasion 
for bleeding. Do not suppose that every slowly 



IMPEDED LABOUR. 181 

dilating os uteri is to be thus treated ; the delay may 
be for the reason, that the uterus is acting in a wrong 
direction, when this method is of no use ; or the os 
uteri may be rigid, dry, hot, and painful, when any 
attempt on your part to dilate it would do mischief; 
it is only in the thick, spongy, cedematous state of 
the os uteri that this kind of artificial dilatation can 
be of service. Pare your nails close, that you may 
not scratch the os uteri, and do not press it upwards, 
and against the symphysis pubes, by which you 
may irritate or injure the urethra, but rather on one 
side of the course of the urethra. The os uteri is 
sometimes thus slipped over the head with the 
greatest facility, and I have been surprised at the 
advantage I have gained by it ; but if this cannot 
be accomplished in ten or a dozen pains, you will 
not succeed at all, and you had better not persevere 
in the attempt. 

It sometimes happens that women become preg- 
nant in whom the os uteri has been destroyed by 
previous disea.se. A case of this kind was related to 
me, by a gentleman on whose veracity I can rely, in 
which, after a miscarriage, extensive sloughing of the 
vagina took place, extending to, or rather compre- 
hending also, the os uteri, in place of which there 
was only a hard contracted circle, as if formed by a 
cicatrix. This woman was attended in her labour 
by three surgeons, all of whom agreed in the fact 
that the os uteri was lost. The labour-pains were 
not sufficient to force the head through this unyield- 
ing portion of the passage ; the head had descended 
low into the pelvis, pushing the lower part of the 
uterus before it. After waiting a considerable time, 
and the strength of the patient being almost ex- 
hausted, it was determined by the professional at- 
tendants to cut an os uteri. The patient was taken 
out of bed, and placed in the position for lithotomy, 
so that the light fell on the vulva: by dilating as 

24 



182 ON DIFFICULT LABOUR. 

much as possible the external orifice, the cervical 
portion of the uterus was apparent, as well as the 
cicatrix in the situation of the os uteri. This part 
was first punctured with a sharp-pointed bistoury, 
and an incision of considerable extent was then made 
with Potts' bistoury. The patient was replaced in 
bed, the labour-pains returned, and the head was 
forced through the opening, rending it right and left. 
Some alarming symptoms now occurred ; and as the 
head descended slowly it was perforated, and she 
was speedily delivered. In forty -eight hours after 
her delivery, this woman had no bad symptoms : 
there was a purulent discharge from the vagina for 
about a fortnight, after which she recovered per- 
fectly, and is now pregnant again. Many similar 
cases, which were treated in the same manner, have 
been recorded : some of them terminated success- 
fully, and others fatally, in consequence of the ope- 
ration having been too long delayed. 

It sometimes happens that the adhesions form in 
one or more portions of the vagina, from inflamma- 
tion, or, perhaps, sloughing. A sufficient opening 
remains for the purposes of menstruation and con- 
ception ; but a considerable impediment is presented 
to the passage of the child's head. If the force of 
the labour-pains is not sufficient to break down 
such adhesions, they must be divided with Potts' 
bistoury. 

We now come to speak of deformity of the pelvis, 
which constitutes by far the most formidable impedi- 
ment to the progress of labour. The dimensions of 
the well-formed pelvis are, at the upper aperture, from 
the pubes to sacrum, four inches and a half: from 
ilium to ilium, five inches and a half; these dimen- 
sions in the lower aperture of the pelvis are reversed. 
The usual dimensions of a child's head of the natural 
size are, from ear to ear, three inches and a half; and 
from the os frontis to the occiput, four inches and a 






IMPEDED LABOUR. 183 

half. If the head of the child is of the customary 
size, the bones in a well-formed pelvis present no ob- 
stacle to its passage into the world. 

The dimensions of the pelvis in different women 
are liable to a considerable variety ; but every narrow 
pelvis is not a deformed one : many women whose 
figures are otherwise good, have narrow hips : they 
are not, however, well made for child-bearing. The 
hips in women are broad and the shoulders narrow ; 
in men the hips are narrow and the shoulders broad. 
There is very little difference in the dimensions of 
the hips of male and female children till about the 
age of nine years, when the female pelvis begins to 
expand, rather preceding the development of the soft 
parts. A narrow pelvis is an imperfection of growth, 
but not a deformity. Deformity of the pelvis is the 
consequence of a disease called rickets, with which 
children are not unfrequently affected. In this dis- 
ease the bones have not their natural firmness, and 
are therefore disposed to become bent and distorted. 
The bones of the pelvis are liable to be thus affected, 
and the distortion which occurs in childhood, when 
the bones are soft, is afterwards continued when they 
have acquired the customary hardness. To an un- 
married woman this is of no consequence ; the de- 
formity will, perhaps, not be detected unless she be- 
comes pregnant, when, at the time of labour, it may 
be found that her pelvis, instead of being four inches 
and a half from pubes to sacrum, is only three inches 
and a half, three inches, two inches and a half, or 
even less. 

Deformity of the pelvis may occur in adults from 
mollifies ossium, and a woman who has had two or 
three easy labours may afterwards have a difficult 
one. This disease is, however, extremely rare. 

Deformity of the pelvis is generally the conse- 
quence of rickets, and it may occur in different di- 
rections. The most frequent deformity is that from 



184 ON DIFFICULT LABOUR. 

sacrum to pubes, and it is produced by the superin- 
cumbent weight of the vertebral column, &c, by 
which the sacrum, when soft from disease, is pressed 
downwards and forwards towards the pubes, and the 
pelvis, in consequence, is more or less contracted in 
the different instances. The bones being soft and 
waxy from disease, the pelvis may be deformed in 
other directions ; the heads of the thigh bones some- 
times press in the acetabula, and the bones of the 
pubes are pressed closer together and made to pro- 
ject in front, or by the pressure of sitting, the ischia 
may be bent, and the arch of the pubes will in con- 
sequence be much contracted. 

There is, however, but one kind of deformity 
which is frequently met with in practice, and this is 
the projection of the promontory of the sacrum 
towards the symphysis pubes — the other varieties a 
person may perhaps not meet with in the course of 
his life, therefore it is this which principally demands 
our attention. It is commonly stated that the child 
may be born alive, though it will be expelled with 
difficulty, if the space between the bones is three 
inches and a half, provided the head is of the usual 
size ; if the space is only three inches, the child will 
not be born alive, though it may be extracted with- 
out perforating the head; if only two inches and 
a half, the child may be extracted by perforating 
the head ; if only two inches, or less, though the 
head may be opened, the child cannot be brought 
through this space, and the woman can then be 
delivered only by the Csesarian section. These 
computations are not to be considered as infallible ; 
for Dr. Clarke and Dr. Osborne have affirmed, that 
when the space between the sacrum and pubes is 
only one inch and a half, by opening the head the 
child may be extracted.* 

* See Lond. Med. and Phys. Jour., vol. vii., p. 40. 



IMPEDED LABOUR. 185 

Tumours about the cervix uteri, vagina, or pelvis, 
ma j impede the descent of the head of the child. 
The gentleman with whom I received the first part 
of my professional education was called to a lady 
whom he had formerly attended in easy labours ; on 
examination, he was perplexed by finding the va- 
gina plugged by a soft, round tumour, which ap- 
peared to be attached to the back part of this canal ; 
he passed his linger up in front of the tumour, and 
felt the distended membranes ; a pain came on, and 
they were ruptured. He could then distinguish the 
head of the child. After several pains, and the lapse 
of a considerable time, the head did not advance; he 
therefore turned the child, and extracted it by the 
feet ; but the tumour so long retarded the passage of 
the head that the child was born in a state of as- 
phyxia; while he was attempting to restore its ani- 
mation, the placenta was expelled naturally, and the 
state of his patient when he left her was in all re- 
spects favourable, except that the tumour still re- 
mained in the vagina. In about six hours afterwards, 
he was informed by a message that another child 
was coming away. On visiting her again, he found 
she had violent bearing-down pains, and, to his great 
embarrassment, he discovered a livid tumour pro- 
truding at the external orifice. He gave her a dose of 

o ..." 

laudanum, but the pains still continued, she became 
weak and pale, and her pulse began to sink. He 
sent for Mr. Rigby, of Norwich, but she expired be- 
fore he arrived. On examination the following day, 
the uterus was found quite contracted, while from 
the posterior edge of the cervix uteri hung, by a 
large neck, a polypus which filled the vagina. Dr. 
Denman relates a similar case. It is difficult to say 
what could have been done in such a case ; there 
can, however, be no question but the polypus, if 
sooner discovered, should have been removed by the 
application of a ligature. This lady did not die 



186 ON DIFFICULT LABOUR. 

from haemorrhage ; and therefore it appears that long- 
continued action of the uterus, whether there be a 
child to expel or not, is capable of exhausting speedily 
the powers of life. 

The birth of the child may also be impeded by 
other fleshy tumours* filling the vagina, or by 
tumours containing a fluid or gelatinous substance. f 
When ovarian dropsy exists during pregnancy, the 
uterus and the ovaries generally go on enlarging at 
the same time. When the labour is over, it is diffi- 
cult to determine by external evidence, owing to the 
enlargement of the abdomen, whether there does not 
remain another child in the uterus. This can be as- 
certained only by passing your hand into the cavity 
of the uterus. But when the ovarian tumours are 
small, as the uterus enlarges they slip into the pelvis : 
and, when labour commences, they descend before 
the head of the child. If a tumour of this kind, or 
one in which a fluctuation can be discovered, should 
fill the vagina so as to impede labour, it must be 
evacuated by tapping it. 

I have now to draw your attention to the size of 
the child's head, as a cause of protracted labour. 
Some children are naturally large : and the dimen- 
sions of the head are usually proportionate to the 
other parts of the body. I have seen a child which, 
instead of the customary weight of eight pounds, has 
weighed sixteen pounds at the time of its birth. 
These enormous heads impede labour very much, 

* Dr. Drew removed, by incision through the perinaeum, a 
solid tumour from the pelvis during - labour, which prevented the 
descent of the child ; it grew from the sacro-sciatic ligament ; 
measured fourteen inches in circumference, and weighed two 
pounds eight ounces. Both mother and child did well. See 
Edinburg Med. and Sur. Jour., vol. i., p. 20. 

f See observations on tumours within the pelvis, occasioning 
difficult Parturition ; by Mr. Park, of Liverpool, communicated 
by Dr. Yelloly, Med. Chirurg. Trans., vol. ii., p. 296. 



IMPEDED LABOUR. 187 

and cause the patient to suffer greatly. But in some 
instances there is a morbid and disproportionate en- 
largement of the head. Children while yet in utero 
are liable to hydrocephalus ; and the head, instead of 
measuring three inches and a half from side to side, 
might measure four or five inches. In the cases of 
this kind which I have met with, the head has been 
situated uppermost, and the feet have presented. I 
was lately sent for to a case in which the feet and 
body of the child had been born a long time, but the 
midwife could not extract the head. The child was 
dead from the compression of the cord ; I perforated 
the head behind the ear, when a quantity of water 
gushed oat, and the head immediately descended. 
The head, however, though enlarged by hydroceph- 
alus, sometimes presents naturally. I should sus- 
pect an impediment of this kind in a case in which 
the head did not descend, though the pains were 
strong, the pelvis well formed, and the os uteri fully 
dilated. I shall recur to the treatment of these cases 
when I have to speak of the use of instruments. 

The head of the child may be of a natural size, 
yet it may be so placed as to impede the progress of 
labour. There are two deviations from the natural 
position : — the first, when the occiput is towards the 
sacro-iliac junction with the face towards the oppo- 
site groin ; the second, when the head is so situated 
as to form a face presentation. In the first of these 
the child descends easily, with its face turning to- 
wards the pubes, and the occiput in the hollow of 
the sacrum, until it begins to pass under the arch 
of the pubes, when, instead of the occiput, which is 
the smallest, the forehead, which is the widest end 
of the oval, comes foremost. Dr. Clarke, who has 
written on these cases,* says, if this position is dis- 

* See Transactions of a Society for the Improvement of Medical 
and Chirurgical Knowledge, vol. ii., p. 229. 



188 ON DIFFICULT LABOUR. 

covered before the head has descended low into the 
pelvis, the pressure of one or two fingers against the 
temple of the child during a pain will correct it, by 
turning the face towards the sacro-iliac junction, and 
consequently the occiput to the opposite groin, when 
the head will be naturally placed. But this presen- 
tation is often fancied when it does not exist, and is 
as often overlooked when it does. Smellie said he 
was not aware of the existence of this misplacement 
until the child was nearly born. The difficulty in 
these cases is overrated. If the face is towards the 
pubes, this position is certainly unfavourable to an 
easy delivery ; but if this deviation is not complicated 
with other causes of impediment, it is of no great 
consequence. To accomplish the delivery may re- 
quire a few additional pains, but not in general the 
use of instruments, as is by some supposed. 

The second position of the head by which labour 
will be impeded is the face presentation ; but if this 
is not complicated with other difficulties, it is merely 
a modification of natural labour, which is, in conse- 
quence, rendered more difficult and tedious. In this 
kind of presentation, the eyes, nose, and mouth, are 
foremost, and thus the head descends into the pelvis; 
the forehead rests on the perinseum, and the chin is 
towards the pubes ; the chin turns under the arch of 
the pubes, just as the occiput does in a natural pre- 
sentation, and is expelled in a similar manner ; but 
the chin may be in the hollow of the sacrum, and 
the forehead towards the pubes. This modification 
of the face presentation is of rare occurrence, and 
the delivery is attended with increased difficulty, as 
the widest part of the presentation has to pass through 
the narrow space between the rami of the pubes ; it 
bears the same relation as regards the difficulty of 
expulsion to the more common face presentation, as 
a fontanelle does to a vertex presentation. It is 
asserted by some practitioners that the face presen- 



INJURIES FROM PROTRACTED LABOUR. 189 

tation requires the application of the forceps; I 
believe myself that it requires only more time, more 
labour-pains, and more patience, than a natural pre- 
sentation. 



(a) ON THE INJURIES ARISING FROM PROTRACTED 

LABOUR. 



Before the practitioner in midwifery can judge how 
long a labour may be safely permitted to continue, 
or at what period artificial delivery is required, he 
must know what evils to expect from its protracted 
duration, and how they may be detected on their 
first occurrence. 

Protracted labour may induce an inflammatory 
state of the uterus, which will be owing to its violent 
and long-continued action, and this state of the uterus 
may be extended to the peritoneum. The natural 
powers may have accomplished the labour, yet this 
inflammatory state may have been induced ; and it 
may terminate fatally, either in a few hours, or in 
two or three days. As labour is itself attended with 
pain, this inflammatory state may not be, readily 
detected. During a labour-pain the woman screws 
up her mouth, bears down, and groans for half a 
minute or so ; the pain being off, she is perfectly easy 
till the next comes on : but when inflammation has 
occurred the pain is constant, though aggravated 
during the action of the uterus. Constant pain in 
the belly, with tenderness to the touch, and a rapid 
pulse, attended with shiverings and vomiting, con- 
stitute the symptoms of incipient uterine and peri- 
toneal inflammation. It is necessary that the pain 
of inflammation should be distinguished at its com- 
mencement from that incident to labour ; for, unless 

25 



190 IMPEDED LABOUR. 

the inflammation is speedily treated by active mea- 
sures of depletion, it will most probably have a fatal 
termination. 

The head having descended low into the pelvis, it 
may become impacted, acting on the soft parts like 
a wedge, by which inflammation and sloughing of 
the vagina may be produced. In this case, also, the 
natural powers may be adequate to accomplish the 
delivery. But if inflammation has been excited it 
may terminate in sloughing, and the patient may 
die from a gangrenous wound. If death does not in 
this stage terminate her sufferings, she is likely to 
exist a most unhappy creature; for the sloughs 
sometimes extend in front into the urethra and blad- 
der, and behind into the rectum, making a commu- 
nication between these passages ; her vagina becomes 
a common receptacle for both urine and fasces ; and 
as these fistulous communications are generally in- 
curable, she remains till death a disgusting object 
both to herself and her husband. 

There may be no inflammation either of the peri- 
toneum or vagina, but the life of the patient, during 
a protracted labour, may be endangered from ex- 
haustion. So long as the strength is not greatly 
reduced, the labour-pains will be regular and vigorous, 
recurring every five or ten minutes : but these actions 
of the uterus are at the expense of the whole consti- 
tution ; the vis vitas becomes exhausted from their 
long continuance, the pains become slow and feeble, 
gradually they cease altogether, and the patient dies. 
I was called to a lady whose strength was much 
exhausted by ineffectual labour, owing to a contracted 
pelvis; I delivered her by opening the child's head, 
and she recovered. I proposed, if ever she became 
pregnant again, to bring on labour at the seventh 
month : she did become pregnant, but chose to go 
her full time, and was attended in her labour by 
an ignorant midwife. The labour-pains were of 



INJURIES FROM PROTRACTED LABOUR. 191 

course ineffectual : they were, however, suffered to 
continue until she was quite exhausted, when I was 
sent for, and arrived only a few minutes before she 
expired. 

How are you to know that the constitution is ex- 
hausted ? I have many times been sent for both by 
old and young practitioners who have supposed their 
patients to be exhausted, and I have often found them 
sweating with pain, kicking and rolling about the 
bed, with a pulse strong, and the uterus acting so 
vigorously as to make them roar : yet in the midst 
of all this display of vigour the women themselves 
have exclaimed that they are exhausted. Never 
mind what their tongues say, but what their pulse, 
uterus, and constitution say. If there is a rapid, 
feeble pulse ; if the pains are slow, weak, and as it 
were dying away, and if the countenance is sunk, 
these are the symptoms of exhaustion, and when 
they occur we have waited long enough. But you 
are not to consider every abatement of the pains in 
labour as a proof of exhaustion. Often in natural 
labour you will find the pains go off, or become very 
slow : but feel the pulse, and you will find it strong 
and rapid ; the labour is becalmed by a suspended 
action of the uterus ; but the uterus may be inactive 
while the powers of the constitution are by no means 
exhausted. Hence the dangers to be apprehended 
from mere protracted labour are three — first, inflam- 
mation of the uterus and peritoneum; second, 
inflammation, sloughing, &c, of the vagina; third, 
exhaustion : — each of which is to be discriminated 
and treated in the manner before directed. 

It has been seen that there are three principal 
varieties of impeded labour, each of which admits or 
requires a different mode of artificial delivery. First, 
if the head is opposed only by a moderate impedi- 
ment, it will descend into the cavity of the pelvis 
long before the patient suffers from protracted labour ; 



192 IMPEDED LABOUR. 

when, if necessary, you may deliver by instruments 
which are harmless both to the mother and child. 
Second, if the impediment is more considerable, the 
patient may be exhausted by protracted labour while 
the child is yet high up : this state admits of de- 
livery : but in order to preserve the life of the mother, 
it will be necessary to sacrifice that of the child. 
Third, if the impediment is of the worst kind, de- 
livery can be accomplished only by the Caesarian 
section. The instruments by which delivery may 
be accomplished with safety both to the mother and 
child, are the forceps, the vectis, and fillet : the last 
is now entirely laid aside ; the two first were not in- 
vented till the middle of the seventeenth century. 
About that time there was in London a family of ac- 
coucheurs, a father and two sons, named Chamber- 
lain, who, it was generally said, possessed a secret 
which enabled them to deliver women without in- 
jury to the mother or child : they would not disclose 
their secret ; they monopolised almost the whole mid- 
wifery practice of London, and of course made their 
fortunes. 

The first account we have of the forceps was in 
the year 1743 : and these instruments were supposed 
to be the same as those which Chamberlain had em- 
ployed, the truth of which conjecture was not con- 
firmed until within the last four or five years.* 
The history which I received from Mr. Carwardine, 
of Essex, runs thus : — Woodham Mortimer Hall, in 
Essex, is an old manor house, and was once the resi- 
dence of old Chamberlain, since whose time it has 
been occupied by several individuals. About four 
years since, Mr. Kemble, in exploring an old closet 
in this house, discovered a trap-door, which being 
opened was found to lead into another closet, in which 
were boxes containing letters, rings, jewels, trinkets ; 

* This was said by Dr. Gooch, in 1818. . 



ON THE EMPLOYMENT OF THE FORCEPS. 193 

among other things old Chamberlain's will, and a 
ring with the hair of Mrs. Chamberlain, which ap- 
peared to have been placed there by her daughter, 
with the following written memorandum : — " This 
lock of hair was taken from my dear mother after 
her death." There were also two bags of instru- 
ments, consisting of different specimens of the forceps 
and vectis : there was a petition also to the House of 
Commons, lamenting the number of deaths occa- 
sioned by ignorant mid wives, and stating that himself 
and sons possessed a knowledge of means by which 
women may be delivered without injury to either the 
mother or child ; and hinting slily, that if the House 
of Commons would grant him a sum of money, he 
would, at their command, disclose the secret. Old. 
Chamberlain was buried in the church-yard near by : 
and on his tomb-stone is engraved " that he was born 
in 1601, and died in 1692, and had been physician 
to three kings ; to wit, Charles the First, Charles the 
Second, and James the Second ; that he was baptised 
when he was forty-eight years of age, after which he 
kept the Sabbath." These circumstances leave no 
doubt that the instruments found in the closet were 
those which Chamberlain employed, which were 
similar to the forceps and vectis now in use, and of 
the application of which I have next to speak. 



(b) ON THE EMPLOYMENT OF THE FORCEPS. 



I have said it is necessary, in the first place, that 
you should be acquainted with the injuries which 
may ensue from protracted labour; and that you 
should be qualified to recognise the earliest symp- 
toms by which their approach is manifested. As 



194 IMPEDED LABOUR. 

long as the uterus acts with regularity and force, 
so long is the patient free from exhaustion. As 
long as there are distinct intervals between the pains, 
and no tenderness of the abdomen on pressure, there 
is no peritoneal inflammation ; and as long as the 
vagina feels of its natural temperature, moist, and 
without tenderness, there is no inflammation of this 
part. When the vagina suffers a long-continued 
pressure, there is danger of its becoming inflamed ; 
and when inflamed, it feels hot, dry, and tender, and 
loses, as a consequence of the inflammation of the 
mucous membrane, the natural secretion by which 
it is lubricated. These symptoms prove that in- 
flammation has already begun; the rapidity with 
which this state is established is in proportion to the 
pressure suffered by the soft parts between the pubes 
and the hard head of the child : but as long as you 
can pass your finger all round between the head of 
the child and the pelvis, and as long as the vagina is 
not hot or tender, and is lubricated with mucus, so 
long is this part free from inflammation. When the 
impediment to the passage of the head of the child 
is only moderate, the head will descend into the 
pelvis long before the injuries of protracted labour 
will occur, and the woman may then be delivered by 
the forceps. When are you to use the forceps ? and 
when are you not to use them ? - If the patient 
suffers from exhaustion, peritoneal or vaginal inflam- 
mation, no man would hesitate a moment on the 
propriety of applying them ; but if ineffectual labour 
has continued so long that a natural delivery seems 
improbable, there being no symptoms of injury from 
protracted labour, the case is less urgent, and admits 
of two opinions. Some say, if you wait a few hours 
the labour will be accomplished by the powers of 
nature ; and if you apply the forceps you do it un- 
necessarily. If you apply the forceps merely because 
you think that the labour will not be completed 



ON THE EMPLOYMENT OF THE FORCEPS. 195 

naturally, it is an evil; but should you permit the 
occurrence of the injuries of protracted labour, by 
withholding assistance, it is a much greater evil ■ 
for when any one of these has taken place, it may 
go on to a fatal termination in spite of the best treat- 
ment. You can never allow the symptoms of ex- 
haustion, of inflammation of the peritoneum orvagina, 
to take place, without the risk of their proceeding 
so far as to be beyond the control of art. But do not 
think that I recommend the employment of instru- 
ments unnecessarily ; for they are an evil, and are 
never introduced into the vagina without some hazard. 
The first time I ever saw the forceps applied, it was 
done with great care by a gentleman as skilful as 
any in this metropolis : but he lacerated the perimeum 
quite into the anus, and the opening remains to this 
day. The first time I used them in the Westminster 
Lying-in Hospital I lacerated the perineum, and 
could not avoid it, though I took special care. Not 
long since a practitioner of great professional ac- 
complishments sent for me to consult with him on 
a most distressing case ;- the head during the labour 
(which had been over four days) had rested a long 
time on the perinaBum : he applied the vectis, using 
it with great care and attention. He succeeded in 
delivering the woman, and believed the labour to be 
well over ; but within twenty-four hours afterwards 
a violent burning pain came on in the vagina, with 
fetid discharge and shiverings, followed by a hot 
skin and rapid pulse; the teeth and tongue soon 
became covered with black sordes : there was low 
delirium; and death soon terminated the scene. 
The death of this patient was occasioned by inflam- 
mation, gangrene, and sloughing of the vagina, pro- 
duced by the pressure of the instrument against the 
soft parts. Even by men who possess more than an 
average share of skill, instruments are never used 
without risk of injury to the soft parts ; the unne- 



196 IMPEDED LABOUR. 

cessary employment of them must, therefore, be 
considered highly reprehensible. 

If the patient has been in labour a great many 
hours, and the head has descended into the pelvis so 
low as to touch the perinseum, it should then be ex- 
pelled in half an hour : but nature sometimes takes 
seven or eight hours to finish the remaining part of 
the process, during a considerable part of which 
time the labour is at a stand, or makes but little 
progress. Still, if the pains are vigorous, and the 
patient free from symptoms of injury from protracted 
labour, the aid of the forceps is not required ; for the 
head does advance, though very slowly. But sup- 
pose the head has been low down many hours, and 
has not advanced in the slightest degree, if the la- 
bour were to remain in this state for twelve hours, 
although there may then be no bad symptoms, I 
should not hesitate to apply the forceps, rather than 
allow the near approach of symptoms which if es- 
tablished may be beyond the control of art. I lately 
attended a lady whose labour was very protracted, 
owing to the feeble action of the uterus. In about 
twenty-four hours after the rupture of the mem- 
branes, the os uteri was fully dilated, and the head 
low down in the pelvis. I expected the labour 
would now have been over in three hours at farthest; 
but the head continued to advance so imperceptibly 
that, like the hour-hand of a clock, you could not 
know that it did advance only by a comparison at 
intervals ; and twelve hours elapsed before the de- 
livery was accomplished. A practitioner who felt 
himself a master in the use of instruments might not 
have chosen to wait in this case for a natural de- 
livery, and to such a one the tardy progress of the 
labour might have been a sufficient apology for re- 
sorting to them. Some practitioners use secretly the 
vectis (which they carry in their pockets as a car- 
penter does his rule) as soon as the head has de- 



ON THE EMPLOYMENT OF THE FORCEPS. 197 

scended sufficiently low, and has become a little 
stationary. I do not recommend you to imitate this 
practice ; but if the head has descended low, if the 
labour has been a long time stationary, and you be- 
lieve that it cannot be safely accomplished by the 
powers of nature, your best practice will then be to 
apply the forceps. I was sent for by an accoucheur 
who had been detained at a labour two days and a 
half. The head had been fixed in the pelvis and 
touching the perinseum fourteen hours. The pa- 
tient's pulse was good, her skin cool, and the pains 
recurred frequently. Under these circumstances I 
said I would wait three hours longer, and if she 
was not then delivered I would apply the forceps 
and deliver her in ten minutes: which I was obliged 
to do after the head had been retained low in the 
pelvis seventeen hours. In such cases as these, 
although a precipitate use of instruments is never 
justifiable, it is better for one who is familiar with 
the application of the forceps to deliver his patient, 
after waiting a moderate time, than to permit the 
continuance of fruitless pains, or hazard the more 
serious evils of protracted labour. 

Having thus settled when we are to apply the 
forceps, the next question is how are we to do it ? I 
take it for granted that the os uteri is fully dilated, 
the membranes ruptured, and the head descended so 
low in the pelvis as just to touch the perinseum. You 
are to place the patient directly across the bed, her 
head to one side and her breech to the other, and let 
the breech come so near to the edge that she fears 
she shall fall off; which of course you will prevent. 
The forceps are to be applied with one blade over 
one ear, and the other over the other ear, of the child. 
But before you apply them you must feel an ear, 
which is in one of two places. The head gener- 
ally enters the pelvis with the face towards the left 
sacro-iliac symphysis, and the occiput towards the 

26 



IQQ IMPEDED LABOUR. 

opposite groin ; in this stage of its descent, therefore, 
one ear will be found towards one groin, and the 
other towards the opposite sacro-iliac symphysis ; but 
as the head descends lower into the pelvis, the face 
turns into the hollow of the sacrum and the occiput 
to the symphysis pubis, when the ears are one 
towards each side of the mother. In proportion as 
the head is high up in the pelvis, so is the ear towards 
the groin ; but in one of these two situations it will 
generally be found. I introduce my finger up be- 
hind the symphysis pubis, and passing it round on 
the head, taking half the circuit of the pelvis, I can- 
not omit discovering an ear. People often say they 
fail in this attempt ; the reason is, either that the 
head has not descended sufficiently low, or that the 
finger is not passed up high enough. The ear is 
generally towards the left groin, sometimes towards 
the right : and when the head is very low down, 
towards ei ther side of the pel vis. The blades of the 
forceps must be introduced upwards and forwards in 
the direction from the anterior part of the perinseum 
to a point above, a little anterior to the promontory 
of the sacrum ; this is the axis in which the head 
may be the most firmly grasped. I pass my finger 
up so high as to feel an ear. I have often been as- 
tonished, on introducing my finger, when the os uteri 
has not quite slipped over the head, to feel the cervi- 
cal portion of the uterus so thin that I have with 
difficulty discovered its margin ; this is a matter 
which requires nice discrimination ; if you were to 
pass up the blades of the forceps on the outside of 
the cervix uteri, the laceration which must result 
would most probably be very soon fatal. 

Having felt the ear, I pass one blade of the forceps, 
previously warmed and smeared with lard, slowly 
and carefully up during the absence of a pain be- 
tween my two fingers and the head of the child, till 
I have introduced it so far that the locking part is 



ON THE EMPLOYMENT OF THE FORCEPS. 199 

near the external orifice : this blade is to be kept 
perfectly steady until the other is applied. There is 
no necessity for feeling the other ear previously to 
the introduction of the second blade ; it is sufficient 
that this is applied exactly opposite to the first ; and 
it also is to be passed up between your two fingers 
and the head of the child, sliding rather than shoving 
it till the locking part of this blade is also near the 
os externum, and exactly corresponds to that of the 
other. Having proceeded thus far, pass your finger 
round the forceps to guard against including any 
skin or hair, and then lock them. If the blades do 
not lock easily, a little attention must be given to ad- 
justing them :'* when they are locked, the handles are 
to be compressed together, and a piece of tape or a 
bandage tied firmly round them to prevent their 
slipping. I will now suppose the forceps to be pro- 
perly applied, when you must proceed to extract. 
This is to be done in the direction of the axis of the 
pelvis, which is a curved canal, the axis of the upper 
aperture being downwards and backwards, that of 
the lower downwards and forwards ; the head must 
be drawn in the same directions, first downwards 
and backwards, and when it begins to distend the 
perinaeumy downwards and forwards. Attention to 
these particulars is of great importance. It is com- 
monly said that you are to pull from blade to blade, 
but if you do this only, the head will not ad vance in 
the slightest degree. You may pull till the sweat 
stands on your nose, and the nurse coolly says, " Had 
you not better wipe the perspiration off your face, 
Sir ? ' ' On the other hand, if you pull quite straight, 
the blades will probably slip off. You are to combine 

* A rule given for the locking of the forceps is to " cross the 
handles on the same sides as the stops, till the blades cross each 
other ; and then press the handles together ; when they are locked, 
the stop will be felt on the outside of each blade." — See a paper 
entitled " Instructions to a Tyro on the Use of the Forceps in Mid- 
wifery." Lond. Med. and Phys. Journal, September, 1820. 



200 IMPEDED LABOUR. 

these modes by an action one-third lateral and two- 
thirds extractive. Thus you first draw downwards 
and backwards with a motion partly lateral and 
partly extractive. You must not work constantly, 
but only during a pain, and desist when the pain 
goes off, and again extract when the pain returns m r 
if the pains are weak and distant, you may renew 
your efforts for a minute or two between them. 
What force are you to use ? Begin very gently, and 
gradually increase the force till you perceive that 
the head advances, when the same force steadily and 
carefully employed will gradually accomplish the 
delivery. A young man not finding that the head 
moves on his first efforts; and seeing the attendants, 
&c, in a state of alarm, is very likely to renew his 
attempts with haste and violence, by which he might 
injure the child and lacerate the perinseum. But 
there is no cause of alarm if the head does not descend 
in five minutes — never mind if it is even half an 
hour ; the requisite force is often much greater than 
a young practitioner may expect; but the lower the 
head has descended, the less is the force required to 
extract it. As the pains recur, you go on extracting 
downwards and backwards, until the head begins to 
distend the perinseum, which then requires support, 
and all difficulty with the forceps is over. You now 
change the direction of pulling to that of downwards 
and forwards. One hand is at this time sufficient to 
manage the instruments, and with the other you 
must firmly support the perinseum, which most 
readily gives way at its extenuated margin. Extract 
with a steady and gentle force, so as not to injure 
the patient, constantly supporting the perinseum until 
the head is delivered. The forceps are now to be 
laid aside, and you are to wait for a pain to expel the 
shoulders and body as in a natural labour. To reca- 
pitulate the rules requiring your particular attention 
in the application of the forceps : First, The os uteri 
must be fully dilated, the membranes ruptured, and 



ON THE EMPLOYMENT OF THE FORCEPS. 201 

the head descended into the pelvis almost so low as 
to touch the perinaeum. Second, The blades of the 
forceps must be applied one over each ear. Third, 
They must be passed up gently, not in the axis of 
the vagina, but in the axis of the upper aperture of 
the pelvis, upwards and forwards ; and take care that 
the blades are so introduced that their locking parts 
correspond with" each other. Fourth, Pull first 
downwards and backwards ; but as soon as the head 
begins to distend the perinaeum, pull downwards 
and forwards, and take especial good care to support 
the perinseum. Fifth, Extract with a compound 
motion, partly straight and partly lateral. 

Perhaps I dwell longer on the application of the 
forceps, and on the several cases which require them, 
than may at first appear necessary to you ; but feeling 
as I do the importance of the subject, and the con- 
viction that no man can practise this department of 
his profession with credit to himself and safety to his 
patients unless he thoroughly understands the use of 
the forceps, my apprehension is that I should rather 
say too little than too much. 

When the head has descended so low as to touch 
the perinseum, and there remain stationary for twelve 
hours, a skilful practitioner will be justified in ap- 
plying the forceps, even though the uterus still acts, 
and there are present none of the symptoms of injury 
from protracted labour. Some, however, might say, 
the interference would then be unnecessary ; but of 
two evils choose the least, and I say that it is a less 
evil to employ harmless instruments unnecessarily, 
than to allow the near approach of symptoms which, 
when once established, may be beyond the reach of 
art. The author of the " London Practice of Mid- 
wifery" (which, though a nameless book, has been 
productive of benefit equal to its extensive notoriety), 
states, that if in six hours after you can feel an ear 
the head is not delivered, you should apply the for- 



202 IMPEDED LABOUR. 

ceps. But here I beg to observe, that it depends on 
how these six hours have been spent, whether the 
head has been all this time perceptibly but slowly ad- 
vancing, or whether the injuries resulting from pro- 
tracted labour have begun to manifest themselves : 
in the latter case, the application of the forceps oijght 
not to be delayed one moment. When I say that 
you should not apply the forceps unless the head has 
descended into the pelvis, almost so low as to touch 
the perineum, and has there remained for twelve 
hours, remember I am not speaking of cases of hae- 
morrhage or of convulsions, or of those in which there 
is danger of injury from protracted labour : but I 
specify this as the time you should wait when there 
is no particular reason for delivery sooner. Gener- 
ally speaking, the os uteri will be fully dilated, 
the membranes ruptured, and the head descended 
low in the pelvis, long before the patient will suffer 
from protracted labour ; but if unfavourable symp- 
toms should arise before the head is so low as to touch 
the perinseum, and yon are compelled to deliver, this 
may often be done by the forceps, without having 
recourse to the perforator, even though the os uteri 
should not be fully dilated. An undilated portion of 
the os uteri sometimes almost as effectually obstructs 
the descent of the head, as a slight projection of the 
sacrum ; and this margin of the undilated orifice of 
the uterus is occasionally so very thin, that a careless 
observer might overlook it. This circumstance re- 
quires your particular notice : for it would be an un- 
fortunate and irremediable occurrence were you to 
lacerate this portion of the uterus in the application 
of instruments. Be cautious in the use of instru- 
ments when the os uteri is not fully dilated, and 
never resort to them in this state of a labour unless 
compelled to do so, by some serious danger which is 
to be apprehended from delay. Many cases of this 
kind I could relate, but one shall suffice : — A lady 



ON THE EMPLOYMENT OF THE FORCEPS. 203 

whom I attended had been a long time in labour ; 
the membranes were ruptured, but the os uteri was 
not fully dilated : I left her to come to this theatre to 
lecture, vowing as I went along that I would apply 
the forceps when the lecture was over. On my re- 
turn, I found the orifice of the uterus still undilated : 
I had reason to apprehend, danger from any addi- 
tional delay, and therefore immediately passed up 
my fingers on the child's head as far as I could, and 
between them and the head I carefully insinuated 
one blade of the forceps, opposite to which I intro- 
duced the other, and having locked them, I delivered 
her in ten minutes. When the head is situated high 
up, great force is sometimes required to move it. I 
once attended a case in the country, in which the 
force required was so great, that had it not been for 
the assistance of a surgeon, who was also in attend- 
ance, I should not have been able to have accom- 
plished the delivery. 

In cases of protracted labour arising from projection 
of the promontory of the sacrum, or other impediment 
preventing the descent of the head low into the 
pelvis, it will be proper to have recourse to the long- 
forceps,* by the dexterous management of which you 
may sometimes be rewarded by bringing a living 
child into the world. These instruments are not to 
be employed without a careful consideration of the 
circumstances of the case, and a conviction of the 
propriety of their use ; the management of them is 
much more difficult and dangerous than that of the 
short forceps; and therefore it becomes the duty of 
a young practitioner, before he attempts to apply 
them, to weigh well his own competency for the 
undertaking. These forceps are to be applied in the 

* The construction of those commonly used in France, called 
Baudelocque's forceps, with the improvement of Dubois, compris- 
ing forceps, blunt hook, and crotchet, is incomparably superior 
to that of any which are made in this country. 



204 IMPEDED LABOUR. 

long diameter of the pelvis : the head being high up, 
you cannot apply them accurately over the ears of 
the child ; the blades must be passed carefully up 
the sides of the pelvis, and will probably grasp the 
head either diagonally, or from face to occiput : if 
the child's nose should be broken, this is not so great 
an evil as perforating its head and letting out the 
brains. It is an important question to determine in 
these cases, whether you will attempt the delivery 
by means of the long forceps, the vectis, or by per- 
forating the head of the child. 

I was called one night to a woman who had been 
in labour about thirty-six hours; the midwife said 
the patient had a distorted pelvis, as the projection 
of the sacrum could be felt, and requested I would 
bring my instruments to open the child's head ; when 
I came, I found she had a projecting sacrum, and 
that the os uteri was not yet fully dilated. I placed 
a pupil with her, with directions to send for me if 
the head did not advance within a certain number 
of hours after the os uteri w T as fully dilated. He sent 
for me at the expiration of the time specified ; I 
succeeded in applying the forceps ; the head did not 
at first yield to my efforts ; at length it did, and I 
delivered her of a living child. This woman has 
been confined since, and the practitioner who attended 
her effected the delivery by perforating the head of 
the child.* 

* I have known the long French forceps employed in two cases, 
at both of which I assisted, with success in each case, owing to 
a deformity of the pelvis ; in previous labours it had been found 
necessary to open the head. In one of the cases alluded to, the 
long forceps, as they are generally constructed in this country, 
which were nine inches in length from the locking part to the 
extremity of the blade, were tried in the first instance, but failed 
totally. The life of one child was preserved ; the other child 
was born in a state of asphyxia, from which it could not be 
recovered. The mother in each case recovered without any 
unfavourable symptoms. 



ON THE EMPLOYMENT OF THE VECTIS. 205 



(c) ON THE EMPLOYMENT OF THE VECTIS. 



Some practitioners prefer the vectis to the forceps. 
There are different modes of applying this instru- 
ment. Some apply it over the occiput ; others be- 
hind the ear, by which it has a bearing against the 
prominence of the mastoid process; and others against 
the chin. The two first are, perhaps, the best when 
the head lies high, as considerable force is required 
to move it ; which may be employed with more 
safety against either the occiput or mastoid process 
than against the chin. But when the head is low 
down and resting on the peringeum, less force will be 
necessary, and the vectis may then be applied against 
the chin ; ^but the instrument requires to be used 
with great caution, lest the jaw should be injured. 
You must never attempt to use the vectis when the 
uterus does not act ; for it is a powerless instrument, 
and only adapted to cases in which the pains are 
rather languid than altogether deficient. Before in- 
troducing the vectis, you should ascertain, by exami- 
nation, the exact situation of the part to which you 
propose to apply it. The curve of the vectis is of 
less diameter than that of the blades of the forceps. 
You proceed to introduce it by first passing one or 
two fino-ers along - the hollow of the sacrum, a§ far as 
may be practicable ; between these fingers and the 
head of the child the vectis is to be cautiously in- 
sinuated ; and, when introduced, you may carry it 
around either side of the pelvis, and apply it to any 
part of the head. The name vectis, which signifies 
a lever, is not perfectly correct; because it implies, 
for the purpose of using it, the necessity of fulcrum. 

27 



206 IMPEDED LABOUR. 

It is to be employed as a hook at the time of a pain ; 
when introduced, you hold the instrument steadily 
with one hand, close to the external orifice, in order 
to preserve its situation ; and when you work with 
it, you must not elevate the handle, for if you do, 
and make the pubes of the mother the fulcrum, the 
intervening soft parts will inflame and slough. This 
instrument is not so good as the forceps, but is more 
easily applied ; it is quite useless when there are no 
pains ; while with the forceps, which require only a 
very little more skill, even though there should be no 
pains, you can deliver in ten minutes. I have no 
faith in the vectis ; it is proper only in a labour which 
is slightly retarded ; if the pains are gone, there is 
the more need of assistance, and we can depend only 
on the forceps. When the head is retained in the 
upper part of the pelvis, if you try the vectis, you 
must place it on the occiput, so that its concavity 
may be applied to the convexity of that part, which 
will, in this case, be towards one or other groin : you 
are, however, to introduce the instrument along the 
hollow of the sacrum, and carry it round to the point 
against which you intend to act. Some practitioners 
are more expert than others in the use of this instru- 
ment, by which a labour may certainly be accelerated, 
if it is employed in a careful and steady manner, 
provided the labour-pains continue. 



(d) ON CRANIOTOMY. 



When the impediment to delivery is more con- 
siderable than that which has just been supposed, 
the evils of protracted labour will take place while the 
head is high up, before it has descended into the 
pelvis ; here you cannot deliver with harmless in- 



ON CRANIOTOMY. 207 

struments both to the mother and child, but you 
must sacrifice the life of the child in order to preserve 
that of the mother. 

The cause of this kind of obstruction is generally 
a projection of the sacrum, as a consequence of rickets 
or mollities ossium, by which the short diameter of 
the pelvis is contracted; and in proportion to this 
projection will be the impediment. The head of the 
child is sometimes so large that its descent is as 
effectually impeded as if there were a contraction of 
the pelvis; or there may be a large head with a slight 
contraction of the pelvis : and, in addition, there may 
be a feeble action of the uterus ; each of these con- 
tributes to retard labour ; and, collectively, they may 
make up a case of the greatest difficulty. I have 
already spoken of those cases of moderate impediment 
in which delivery may be accomplished by the for- 
ceps ; I have now to call your attention to those cases 
of more considerable impediment, in which delivery 
can be effected only by diminishing the bulk of the 
head. In these cases the head will continue to rest on 
the upper aperture of the pelvis, where the obstruction 
to its descent is such that in order to accomplish the 
delivery, it is necessary to make an opening into it 
which will permit the removal or escape of the brain. 
How are you to detect a deformity of the pelvis ? 
Many persons suppose when a woman has a deformed 
back and legs, that she has also a deformed pelvis ; 
but this is a great mistake ; I have known many a 
straight back joined to a deformed pelvis, and many 
a roomy pelvis in those who have had curved backs. 
Indeed, I may say that the back is generally straight 
where the pelvis is deformed. The first fee I re- 
ceived after I settled in London, was from a young 
man who was desirous of marrying a lady whose 
back was crooked, but feared to do so, having under- 
stood that pregnancy may be fatal to her. I told 
him not to be deterred by this apprehension, but to 



208 IMPEDED LABOUR. 

marry her, and when she fell in labour to send for 
me; * hich he did, and having a roomy pelvis, she 
was safely and easily delivered. You cannot tell 
whether the pelvis is deformed except by an exami- 
nation per vaginam. If in a common examination, 
you feel the promontory of the sacrum, rest assured 
there is deformity ; for this cannot be done in a well- 
formed pelvis. If, notwithstanding, the pelvis is well 
formed, the pains strong, and the os uteri fully 
dilated, the head does not descend, the impediment 
most probably consists in the preternatural size of 
the child's head, which will also be suggested or 
confirmed by the peculiarity presented to the touch 
on examination per vaginam. The bones in an 
hydrocephalic head feel as if separated by membrane, 
the sutures appearing like extended fontanelles. In 
this case, as well as when the pelvis is narrow, to 
deliver the woman we must diminish the size of the 
head by perforating it, but this should not be done 
so long as there is the slightest probability either of 
a natural delivery, or of delivery by the forceps. 
Suppose the pelvis is narrow, and we detect it at the 
commencement of labour, what are we to do ? As 
long as the uterus is active, and the head advances 
in the most trifling degree, and the patient suffers 
no bad symptoms from protracted labour, we must 
not perforate ; but after twenty-four hours continued 
and regular action of the uterus, or after twelve 
hours from the full dilatation of the os uteri, though 
the pains continue strong, if the head remains sta- 
tionary, resting on the upper aperture of the pelvis, 
we are justified in proceeding to perforate ; for there 
is no probability that the child will be expelled by 
any efforts of the uterus. But if any unfavourable 
symptoms appear, such as those formerly said to 
occur from protracted labour, or if the pains cease, 
the sooner we apply the perforator the better. It is 
difficult to give a precise rule which will be proper 



ON CRANIOTOMY. 209 

in all cases; but it may be said generally, that it is 
b etter to destroy the child, even unnecessarily, than 
allow symptoms to occur which will seriously en- 
danger the life of the mother. My predecessor, 
Dr. Thynne, used to say, that you had better open 
six heads unnecessarily, than lose one woman, or let 
her go about with the cloaca of a hen. 

Before we use the perforator it is our duty to give 
the child every chance consistent with the safety of 
the mother, by the trial, if practicable, of the long 
forceps, or of the vectis. Supposing it, however, set- 
tled that you must perforate the head, how will you 
do it ? Previous to the introduction of the perforator, 
you place the patient across the bed in the same 
manner as preparatory to the application of the for- 
ceps ; you then pass your whole hand into the vagina, 
and apply your fingers to the head of the child, and 
feel for a suture where the perforation will be made 
the most easily ; but if you cannot feel a suture, or 
fontanelle, you may proceed to perforate the middle 
of the presenting part of the head. The perforator 
must be passed up along the palm of the hand which 
is in the vagina : but before making the puncture 
you must take especial care that there is no undilated 
portion of the uterus in the way ; this being ascer- 
tained, you push the perforator with firmness into 
the head up to the stops ; then open wide the handles, 
or direct an assistant to do it, by which the bones 
will be separated in one direction, then turn the in- 
strument and separate the handles in the same 
manner as before, so as to lacerate the parts of the 
cranium opposed to each blade in an opposite di- 
rection. Having thus made a considerable opening 
in the skull, you break down the brain with the per- 
forator, by turning it round and round in every di- 
rection ; this being done, the longer you delay the 
extraction the less force will be necessary, as the brain 
will be gradually forced out, and the bulk of the 



210 IMPEDED LABOUR. 

head diminished by the compression it will after- 
wards suffer. In delaying the extraction after the 
skull is opened, yon will be guided by the state of 
the patient ; if there is no urgent cause for delivery, 
you will render the subsequent part of the operation 
more easy by waiting a short time : but if peritoneal 
or vaginal inflammation, or constitutional exhaustion 
should be present, or even apprehended, the extrac- 
tion should not be delayed. In order to accomplish 
this, the crotchet (if this instrument is employed) is 
to be passed into the opening of the skull made by 
the perforation, and some firm hold is to be felt for 
where it may be securely fixed : you must take great 
care that it does not slip during the process of ex- 
traction, for if it does it may produce a frightful 
laceration. It is a diabolical instrument; even in the 
hands of the best practitioner it is a dangerous one. 
I never myself met with any accident in the use of 
it, not because it did not sometimes slip, but because 
I chose rather to lacerate my hand than my patient's 
vagina. I shall never use it again : but instead of 
it, an instrument somewhat resembling lithotomy 
forceps, rather larger and longer, with teeth at the 
extremity of each blade, by which the hold is ren- 
dered very firm. You pass it closed up the vagina, 
and when it arrives at the opening in the skull the 
handles are separated ; one blade is introduced within 
the opening, the other is on the outside, and closing 
the handles you grasp a portion of the skull. The 
extraction is to be made carefully, at first downwards 
and backwards ; but when the head presses on the 
perinseum, downwards and forwards,^ if the bone 
which is grasped by the forceps gives way, extract 
it, and grasp another portion. This is an old instru- 
ment, the invention of which is claimed by Lamotte. 
In cases of great deformity of the pelvis, you cannot 
extract all the bones of the head together ; you must 
then pull away each bone separately ; after having 



ON ARTIFICIAL PREMATURE LABOUR. 211 

thus taken away the frontal, parietal, occipital, and 
temporal bones,' nothing of the skull remains but the 
base : experience has shown that the delivery will 
now be best accomplished by converting what re- 
mains of the head into a face presentation. If there 
should be an impediment to the passage of the body, 
the thorax must be opened, as this may be distended 
with fluid. The abdomen may also be distended 
either by fluid or air ; this also is to be punctured, if 
necessary, when the remaining parts will pass easily. 
Hydrocephalus is not a very uncommon disease while 
the child is in the uterus, but hydrothorax or ascites 
is rare. 



(e) ON ARTIFICIAL PREMATURE LABOUR. 

In cases of great deformity of the pelvis, the child 
in utero, if it attains its full growth, must be des- 
troyed ; but if the patient falls in labour six weeks 
before the full period of gestation, experience has 
shown that the woman may be delivered safely ; and 
the child, though prematurely born, will oftentimes 
live. From this observation the practitioners of 
midwifery have been led to consider the propriety of 
bringing on premature labour artificially, and the 
results of experience have been so far favourable to 
this proposition, that the practice may be said to be 
an established one in this country.* The principal 
questions are, at what time, and in what manner, is 
labour to be artificially induced? If this is done at 
six months, the child is small enough to pass through 

* See Cases of Premature Labour, artificially induced for Dis- 
torted Pelvis, with Observations, &c, by Dr. Merriman.— Med. 
Chirurg. Trans., vol. iii., p. 123. 



212 - IMPEDED LABOUR. 

the pelvis, but too young to live. At eight months 
it is old enough to live, but most probably too large 
to admit of easy delivery. What then is the period 
at which the child may be small enough to pass 
through the pelvis, and yet large enough to live ? 
" experientia docet." The answer is, at the comple- 
tion of the seventh month : fix on that period , reckon 
seven calendar months and one week from the time 
of the last menstrual discharge, and then bring on 
premature labour. If the deformity is very con- 
siderable, the child may, even at this time, be too 
large to pass. It is difficult to ascertain the exact 
measurement of the pelvis, but it may, in some 
degree, be guessed at, by the facility or difficulty 
with which the body and limbs of the last child were 
extracted after opening the head. If, however, you 
could get the measurement of the pelvis, you cannot 
get that of the child's head. This operation has 
been performed but once on the continent, and then 
it did not succeed. The continental practitioners 
are as reluctant to induce labour artificially, as we 
are to perform the section of the symphysis pubis. 
Although, then, it cannot be said that the plan of in- 
ducing labour artificially is an infallible one for 
preserving the life of the child, still it affords a 
probability of this success ; at all events it will render 
the labour more easy, and less dangerous to the 
mother. 

The methods of performing the operation which 
will be followed by labour, are two. The common 
one consists in puncturing the membranes with a 
male or female catheter; if the male catheter is 
chosen, it must be made straight before it is used. 
Place the patient near the edge of the bed in a 
proper position, introduce your finger up to the os 
uteri, carry the catheter up on your finger, and with 
great care insinuate it through the orifice of the 
uterus; press it onwards and puncture the mem- 



ON ARTIFICIAL PREMATURE LABOUR. 213 

branes : when the water flows withdraw the catheter 
and leave the patient. The liquor amnii will come 
off slowly ; and after some hours, generally between 
twenty-four and forty-eight, though in some cases 
it may be three, four, or five days, the uterus will 
act. As the liquor amnii drains away, the sides of 
the uterus collapse on the hard substance of the 
child, uterine action commences, and goes on to the 
expulsion of the child. 

The second method of inducing premature labour 
is to pass the hand completely into the vagina, and 
introducing your fore-finger gradually through the 
os uteri, peel off the membranes all round the cervi- 
cal portion of the uterus ; after which, it is found that 
the expulsive action of the uterus will generally come 
on in about forty-eight hours. The advantage of 
this method is that you have the unruptured mem- 
branes to dilate the os uteri, and the liquor amnii to 
defend the head of the child. If premature labour 
does not come on in two or three days from the sepa- 
ration of the membranes from the neck of the uterus, 
you must have recourse to the first-mentioned oper- 
ation of puncturing them. 

Foreigners are exceedingly afraid of this operation ; 
and certain it is, that great disturbance of the nervous 
system is produced by it ; severe rigors, rapid pulse 
and delirium are the occasional consequences, but 
these symptoms, proceeding from neryous irritation, 
do not continue long enough to produce any serious 
consequences : they sometimes cease as soon as the 
pains commence ; and if not then, they cease after 
the uterus is emptied. About nineteen children 
have been thus prematurely born, and afterwards 
reared in this country. This practice, therefore, 
gives a chance of preserving the life both of the 
mother and child. 

No case can occur, the management of which will 
be so difficult as that of an arm presentation with 

28 



214 IMPEDED LABOUR. 

deformity of the pelvis. This combination of cir- 
cumstances has proved too much for the skill of the 
most experienced practitioners. 



(f) SECTION OF THE SYMPHYSIS PUBIS. 



This operation has been recommended in deformity 
of the pelvis, as a mode of facilitating the birth of 
the child. The objections against it are decisive. If 
you divide the symphysis pubis by an incision 
through it, you will find that you do not increase 
the diameter of the pelvis, in the direction in which 
it is contracted, which is generally from sacrum to 
pubes. The room which this operation gives is in 
the lateral direction ; you therefore gain no increase 
of the capacity of the pelvis, where it is chiefly re- 
quired. Further, the bones after being thus divided 
may not unite ; and the bladder is liable to be injured. 
The operation has been performed in this country 
but once ; and in that case, strange to say, it suc- 
ceeded ; but, in ten days afterwards, the woman 
died, not from the operation, but from drinking porter 
and brandy. 



(g) THE OESARIAN SECTION. 



This operation is performed only when the defor- 
mity of the pelvis is so great that even after perfo- 
rating the head, and removing the bones of the 
cranium, there is not sufficient space for the extrac- 
tion of what remains of the child. If such a defor- 
mity is known to exist, no advantage would be gained 



THE CAESARIAN SECTION. 215 

by opening the head, as the Caesarian operation must 
afterwards still be resorted to, which if the head had 
not been opened would have afforded an equal chance 
to the life of the mother, and would probably preserve 
that of the child. On the continent they prefer 
resorting to the Caesarian section, or to a division of 
the symphysis pubis, to any mode of delivery which 
necessarily involves the sacrifice of the child. But 
English practitioners, impressed by the danger to 
which the mother is exposed, never recur to the 
Caesarian section, unless under circumstances which 
must otherwise be alike fatal both to the mother and 
child. The operation has been performed in this 
country about thirty times, and in no single instance 
has the woman recovered. There is a case in which 
the mother is said to have survived the Caesarian 
section, related by Mr. Barlow in the Medical 
Records and Researches. He cut through the 
parietes of the abdomen, and then came, as it was 
supposed, to the uterus, which was no thicker than 
the peritoneum. This I conceive was no uterus at 
all. It must have been an extra-uterine foetus, or 
the foetus had escaped by a rupture of the nterus. 

The method of performing the Caesarian operation 
is this : — Take the woman out of bed ; lay her on a 
table, with her shoulders a little elevated ; make an 
incision six inches in length through the abdominal 
parietes ; it is recommended by some to make this 
incision through the linea alba ; by others, trans- 
versely, from the linea alba to the left side. The 
greater length of the opening must be made below 
the umbilicus, and the place of the incision must be 
determined as circumstances indicate : for sometimes 
the uterus is displaced by the deformity which renders 
this operation necessary. Having laid bare the peri- 
toneum, you open it to the whole extent of the ex- 
ternal incision ; the uterus is then exposed to your 
view, through the side of which, commencing at the 



2\Q IMPEDED LABOUR. 

fundus, you make an incision of sufficient extent to 
enable you to remove the child : this being done you 
separate and take away the placenta ; the uterus pre- 
sently contracts and sinks into the pelvis ; out gush 
the bowels through the wound ; this must be pre- 
vented if possible by an assistant, but if the intes- 
tines do protrude they must be carefully returned ; 
the external wound is to be closed by sutures 
(avoiding the peritoneum) supported by straps of ad- 
hesive plaster, a compress and bandage. If any vessel 
is wounded during the operation, the bleeding from 
which may be troublesome, it should be secured by 
ligature. If a woman dies suddenly in the latter 
periods of pregnancy, by performing the Caesarian ope- 
ration the child may be sometimes preserved. Cases 
are on record in which living children have been 
thus extracted : in one instance the child was taken 
alive from the uterus when the mother had been dead 
nearly half an hour. This formidable and truly 
dangerous operation being over, and the woman 
again placed in bed, the practitioner now oil looking 
at his patient finds her much altered ; her counte- 
nance is sunk, her pulse quickened, and her respira- 
tion hurried — effects of the impression made on the 
general system by an extensive wound in an organ 
so important as the uterus; the nervous system has 
not energy to sustain so violent a shock, and in a few 
hours the patient dies. 

Although on the continent instances are said to 
occur of the success of this operation, yet it must be 
confessed that in general it terminates fatally. In 
one case the width of the pelvis was two inches and 
a half, and the patient died in three days after the 
operation. In England we should have perceived 
there was sufficient room for extracting a dead child ; 
we should therefore have opened the head, and saved 
the mother. Suppose you have opened the head, 
and cannot afterwards extract the child, how are you 



ON PRETERNATURAL PRESENTATIONS. 217 

to act? Practitioners frequently declare that the 
child cannot pass, yet, in many cases, with dexterous 
management, its delivery may be accomplished. Dr. 
William Hunter says, in such cases a very little ad- 
ditional space will suffice for the delivery, which 
may be given by dividing the symphysis pubis; but 
this is a most deplorable alternative, and I scarcely 
know whether this or the Caesarian section deserves 
the preference. 



Section II. — On Preternatural Presentations. 



The child in utero is generally so placed that its 
head is downwards, or "presents" as it is termed. 
But this position, though so common that practi- 
tioners rarely expect any other, is not invariable. 
Preternatural presentations are those of the feet, 
breech, and arm : writers on midwifery describe 
others, as of the shoulder and knees ; but these are 
only modifications of the arm and feet presentations. 
Presentations of the back and belly are also spoken 
of, but Dr. Wm. Hunter did not believe them to 
be possible ; the presentation of the belly has, per- 
haps, been erroneously inferred merely from a pre- 
sentation of the funis. If we know how to manage 
three first deviations from the natural position of the 
child, we know how to manage all. 



218 ON PRETERNATURAL PRESENTATIONS. 



(a) ON THE PRESENTATION OF THE FEET. 



Although you may sometimes suspect this presen- 
tation from perceiving an elongated tumour instead 
of the hard and round head, yet it cannot, in general, 
be ascertained until the os uteri is somewhat dilated, 
and the membranes ruptured. Every part of the 
child which can present has some distinguishing 
characteristic ; thus the hand has a thumb, and the 
foot a heel. In a foot presentation, the expulsion of 
the feet, breech, and umbilicus, may be left to nature, 
but after the umbilicus is expelled, the funis will 
suffer compression, and the child may die from 
asphyxia, as we should do from pressure on the 
trachea. Whether, therefore, the child is to be born 
alive or dead, will depend upon the time occupied in 
accomplishing the remaining part of the delivery. 
As the natural process of expulsion is commonly, in 
this stage, tardy, the delivery of the arms, breast, 
and head must be facilitated by manual aid. The 
head should be in the most favourable position for 
its descent and extraction, with the face to one sacro- 
iliac junction, and the occiput to the opposite groin ; 
as it descends, the face turns into the hollow of the 
sacrum, and the occiput to the pubes. Remember, 
when the feet are protruded, to inform yourself in 
what way the head is coming down ; this you will 
know by the position of the toes, for the face is in a 
corresponding direction. If, therefore, the toes are 
turned in the wrong direction, as towards the pubes, 
wrap a napkin round the feet, and as much of the 
child as you can, and gently turn them to the nearest 
sacro-iliac junction. If a pain comes on, you must 



BREECH PRESENTATION. 219 

desist, for the child is then firmly grasped by the 
uterus ; you must attempt this change of position 
only between the pains. The child being thus 
favourably placed, let nature expel the umbilicus : 
when this is accomplished, pull down a loop of the 
cord a little way, for if the funis be only straightened, 
it is as hurtful as compression ; and then begin to 
extract, in which there must be no unnecessary delay, 
as the child will be dead if it is not now born in a 
few minutes. Compression of the cord is generally 
indicated by a convulsive action of the body of the 
child. When the umbilicus is expelled," I say, 
Nature ! you have done your work ; I must now 
begin mine — so I grasp the breech with a napkin, 
and proceed to extract carefully, but as fast as I can, 
working from hip to hip. As soon as the body is 
born, bring down the arms ; pass up your finger 
from the shoulder to the elbow, and pressing it towards 
the chest, bring down the fore-arm, making it sweep 
over the face ; lift up the body of the child, and ex- 
tract the other arm in the same manner ; the arms 
being brought down, pass up one or two fingers on 
the breast of the child, and introduce them into its 
mouth ; press the chin down to the breast ; with the 
other hand raise the child towards the pubes of the 
mother, extracting at the same time in the direction 
downwards and forwards ; the delivery will thus be 
readily accomplished. 



(b) BREECH PRESENTATION. 



If the membranes are entire, you may at first 
mistake this presentation for that of the head ; if the 
membranes are ruptured, you will generally find 
your fingers, after an examination, soiled with 



220 ON PRETERNATURAL PRESENTATIONS. 

meconium, but this is not an infallible sign ; if, how- 
ever, your fingers are soiled with meconium, and the 
presenting part gives the sense of a soft, round tumour, 
most probably it is the breech ; you will also dis- 
tinguish the organs of generation, and frequently 
you may pass up your finger and feel the groin. 
The efforts of nature are, in general, sufficient to 
accomplish the delivery in cases of breech presenta- 
tion. The breech may, however, if the action of the 
uterus is weak, remain in the pelvis for twenty-four 
hours ; still it may be left to nature, if it advances, 
though ever so slowly. When the breech is low 
down, we have it in our power to render assistance, 
not by instruments, but .by passing one or two fino-ers 
of each hand into either groin, which will enable us 
to use, with perfect safety, any degree of force which 
may be requisite ; the blunt hook, which is sometimes 
recommended, should not be used unless circum- 
stances render it indispensable ; for, unless employed 
with great caution, it will abrade the skin, or may 
even fracture the bones of the child. A soft hand- 
kerchief, when practicable, may be introduced over 
the groins; you then have both ends to pull at, by 
which you can command great power of extraction. 
Remember to observe whether the breech is towards 
the pubes ; if not, turn it, so that the face may be 
towards the sacrum. It is not necessary to brino- 
down the feet ; on the contrary, it is better to allow 
the lower extremities to descend doubled on the body 
until they are free of the external orifice, when the 
breech presentation becomes converted into a footlino- 
case, and requires the same management. The 
extraction of the shoulders and head should be made 
at the time of a pain, which may be sometimes ex- 
cited by gentle friction above the pubes. 

When the pelvis is narrow, and the breech is 
obstinately retained, you may use the forceps, as in 
the head presentation : but the parts over which they 



BREECH PRESENTATION. 221 

are applied being soft, the blades will be very liable 
to slip ; or the blunt hook may be passed carefully 
up into the groin. If the impediment to the descent 
of the breech is trifling, it may be overcome by the 
use of the blunt hook, or by the force which may be 
exerted by the fingers passed into the groins of the 
child. If deformity of the pelvis, in a case of breech 
presentation, is known to exist, it will be proper to 
bring down the feet as early as may be practicable. 
The deformity which impeded the descent of the 
breech may perhaps prevent still more effectually 
that of the head. The delay occasioned by an im- 
pediment of this sort will be fatal to the child ; never- 
theless, you cannot employ with impunity any degree 
of force for the extraction of the head ; for it is pos- 
sible that the body, by such force, may be brought 
away, while the head is left in the uterus.* All 
other means of extraction having failed, it becomes 
necessary to have recourse to the perforator, and to 
open the head : this you do behind the ear, or in the 
most eligible part the nature of the case will admit 
of; when with such moderate extractive force as the 
body and limbs will sustain, or by means of the 
crotchet or hook passed into the aperture of the skull, 
the delivery of the head may be accomplished. 
Great attention must be paid, during this process, to 
the safety of the soft parts ; and that of the perinseum 



* This rare accident is occasioned by improper violence, most 
commonly, when putrefaction of the foetus has already commenced. 
The chief difficulty in extracting the head from the uterus, when 
separated from the body, arises from the difficulty of fixing it ; 
this should be done by the hands of an assistant on the outside 
of the patient's abdomen ; the head is next to be opened by the 
perforator in the most convenient situation, and the crotchet, or 
Lamotte's forceps, should be introduced into the opening, by 
which the rolling of the head will be prevented, before the per- 
forator is withdrawn. The delivery is then to be completed, as 
directed under the title " Of Craniotomy." 

29 



222 ON PRETERNATURAL PRESENTATIONS. 

must be particularly remembered at the time of 
extraction. 



(c) ON THE PRESENTATION OF THE ARM. 



When the shoulder or arm presents, the child lies 
across the pelvis : and, as long as this position con- 
tinues, delivery is impracticable. The arm may be 
readily distinguished by feeling the hand and fingers ; 
but the shoulder is not at first so obvious, being liable 
from its softness to be mistaken for the breech. By a 
careful examination, however, a mistake of this sort 
may be easily corrected ; for you may distinguish 
the scapula, part of the neck, axilla, or arm. The 
shoulder is less round than the breech : there is an 
absence of the genitals, and of the tuberosity of the 
ischium : and the fingers will not be soiled with 
meconium. As the child cannot be delivered when 
the arm presents, for the reason that it lies across the 
pelvis, so it becomes necessary that this position 
should be changed, which is done by the operation 
usually called turning. Ambrose Pare, the cele- 
brated French surgeon, has the merit of bringing 
this method into general practice. At what period 
of labour, and in what manner, is the operation of 
turning to be performed: If you choose the time 
when the os uteri is but little dilated and the mem- 
branes entire, the hand may be passed into the uterus ; 
and the membranes being ruptured, the child will 
be turned with as much facility as if in a bucket of 
water: but in this early stage, the os uteri being 
imperfectly dilated, will probably grasp the head, 
and so delay its descent, that the life of the child 
will be lost. When the os uteri isTully dilated, and 
the liquor amnii has escaped, you may easily pass up 
your hand; but much difficulty and danger will 



ON THE PRESENTATION OF THE ARM. 223 

attend the operation of turning. At this time the 
uterus will be stimulated to vigorous contraction, and 
it may suffer a laceration which will prove fatal to 
the patient. If the os uteri is fully dilated, and the 
membranes are not yet ruptured, your object may be 
accomplished with great ease; you introduce your 
hand and rupture the membranes ; your arm plugs 
up the vagina, and prevents the escape of the liquor 
amnii ; and you may then turn and extract under the 
most favourable circumstances. This is the time 
we should prefer ; but we are not always favoured 
with a choice. It may be a question, in some cases, 
whether you should wait for the complete dilatation 
of the os uteri, by which you will incur the risk of 
a rupture of the membranes. If the os u teri is opened 
to the size of a crown-piece, and at the same time 
feels soft and dilatable : if the vagina and os ex- 
ternum are relaxed ; and if, also, it is not the first 
child ; — under these circumstances, it would be proper 
to introduce the hand, dilate the os uteri, rupture the 
membranes, and proceed to turn, rather than hazard 
the escape of the liquor amnii before this operation is 
commenced. When the os uteri, vagina, &c, are 
rigid and unyielding, some delay will be advisable, 
provided there are no urgent symptoms requiring a 
speedy delivery ; and when the os uteri is but little 
dilated, the practice of turning is highly objectionable. 
If the membranes are ruptured after the labour has 
made some progress, no time should be lost in bring- 
ing down the feet ; for the water will not all be 
evacuated at once, but by the continuance of the 
pains : and, as the water escapes, the child becomes 
more firmly embraced by the contracting uterus. 
When the action of the uterus is very violent, it is 
sometimes recommended to take away twelve or six- 
teen ounces of blood from the arm, to diminish its 
powers : this is seldom necessary ; but it is very de- 
sirable, before you attempt to turn, to render the 



224 ON PRETERNATURAL PRESENTATIONS. 

uterus less active, by giving a large dose of lauda- 
num ; the presence of the hand in the uterus will, 
otherwise, excite an almost uninterrupted contraction; 
during these contractions the hand must be laid flat, 
and the action of the uterus thus suffered to expend 
itself; but this action is renewed the instant you 
raise your knuckles. Seventy or eighty drops of 
laudanum should, therefore, be given ; this begins to 
produce its effect in about twenty or thirty minutes : 
in three-quarters of an hour the contractile efforts of 
the uterus will be so much diminished that there 
will be a temporary suspension of the pains ; and this 
is the favourable opportunity which you are to em- 
brace for accomplishing the delivery. 

After smearing the back of the hand and fingers 
with lard, the fingers are to be formed into a cone, 
and thus the hand is to be introduced through the 
vagina into the uterus, dilating the parts in its pas- 
sage gently but perseveringly. It is of importance 
in turning, that the hand should be carried up in the 
direction of the feet of the child ; some practitioners 
are negligent of this advantage, and then have to 
seek for the feet while the hand is in the uterus. 
The danger of lacerating the uterus is very great 
when the membranes are ruptured, and the liquor 
amnii has escaped; the parietes of the uterus are 
then firmly contracted on the child, and the slightest 
inequality of pressure against it will sometimes be 
sufficient to cause laceration. Never, therefore, 
proceed in the operation of turning during a pain : 
when the uterus is contracting act with caution, 
always lay your hand flat until the pain is over, and 
resume your efforts during the interval of its recur- 
rence. Which hand will you employ ? and how are 
you to know in what direction the feet lie, so that on 
introducing the hand you may immediately find 
them ? the feet of the child are on the same side of 
the uterus as its belly ; if, therefore, the back of the 



ON THE PRESENTATION OF THE ARM. 225 

child is towards the mother's belly, use your left 
hand ; if the belly of the child is towards the belly of 
the mother, use your right hand. By observing the 
position of the child's hand, you may ascertain this : 
the back of its hand is on the same side as its 
back, and the palm on the same side as its belly. 
If the child's back is towards the mother's belly, 
and you introduce your right hand into the posterior 
part of the uterus, the grasping side of your hand 
will be towards the mother's spine, and the back of 
your hand against the feet of the child ; and if you 
pass it into the anterior part of the uterus, you will 
find nothing but the child's back; but if, in this 
relative situation of the child, you pass your left hand 
into the posterior part of the uterus, the feet will 
come immediately within its grasp. If the palm of 
the child's hand is towards the mother's belly, so will 
be its belly and feet. In this case, if you introduce 
your left hand, on arriving at the feet, the palm, or 
grasping side of the hand, will be towards the sur- 
face of the uterus, and the back towards the feet of 
the child ; but if you introduce your right hand, on 
reaching the feet the grasping side of the hand will 
be towards them. The rale, then, for the employ- 
ment of either hand in the operation of turning is 
this : — If the palm of the child's hand is towards the 
abdomen of the mother, you are to pass up your 
right hand into the anterior part of the uterus ; if 
the back of the child's hand is towards the belly of 
the mother, you are to pass up your left hand into 
the posterior part of the uterus. In every turning 
case you are to introduce your hand by the side of the 
presenting part ; as the feet are brought down this 
goes up. If both feet cannot be readily grasped and 
brought down together, bring down one first, and 
then the other; and in the progress of extraction, 
remember to attend to the direction of the axis of 
the pelvis. Dr. Thynne was called to a case in 



226 ON PRETERNATURAL PRESENTATIONS. 

which the attending practitioner could not turn ; the 
failure arose from his having attempted the operation 
only with his right hand when the back of the child's 
hand was towards the mother's belly. Dr. Thynne 
introduced his left hand, and turned the child with 
facility. 

Sometimes when the hand or shoulder presents, 
the head rests on the edge of the brim of the pelvis; 
and if you return the presenting part, the uterus is 
so stimulated to a vigorous action, by the introduc : 
tion of the hand, that the head is thrown off the 
brim of the pelvis, and descends as in a natural 
presentation. I have succeeded in this way in many 
cases, and in some to which I was called for the 
express purpose of turning ; while apparently only 
making a common examination, I have returned the 
presenting part, and then waited for a pain, which 
has brought down the head. I have then desired 
the attending practitioner to examine, and he has been 
surprised to find that the arm was converted into a 
head presentation. On one occasion when the arm 
presented I pushed it up, and down came the funis, 
which I carefully replaced ; the uterus immediately 
contracting forced down the head, which of course 
continued to be the presenting part until it was ex- 
pelled. In arm presentations when the body of the 
child is completely across the pelvis, you must turn 
and deliver ; but if the head is only a little removed 
from its natural position, then return the hand, in 
the hope that the head at the next pain will assume 
its place. Two queries here suggest themselves : 
the first, If when the head is but little removed from 
its natural position, the labour were allowed to pro- 
ceed without interference, would not the position of 
the child become transverse relatively to the pelvis, 
as the arm was forced lower into the vaoina ? The 
second, If an arm presentation were detected in a 
very early stage of the labour, would it not be found 



ON THE PRESENTATION OF THE ARM. 227 

that the head was always only a little removed from 
its customary position ? 

It has been asserted by some writers when the arm 
at first presents that this recedes, and the breech 
takes its place ; this is called a spontaneous evolution. 
Dr. Denman stated that the breech is made to de- 
scend, and at the same time the arm goes up, by the 
continued action of the uterus. In proof of this fact, 
he published several cases,* together with the infer- 
ence that arm presentations may be entirely left to 
nature ; this conclusion was, however, invalidated 
by his subsequent experience. Dr. Douglas denies 
this change of position altogether; he observes, that 
when the arm and shoulder are pushed under the 
arch of the pubes additional space is gained at the 
back part of the pelvis, the breech is forced down, 
distends the perinaBum, and the child is born double. 
This I consider the more correct explanation.! 
Whatever may be the nature of the process, it is one 
we should never be justified in waiting for ; the 
delay must be extremely hazardous to the mother, 
and almost certainly fatal to the child. If it should 
be ascertained that this change of position has already 
commenced, you may wait and observe its progress : 
in all probability the labour will be accomplished by 
the powers of nature, if the action of the uterus con- 
tinues. In the earlier stages of pregnancy, when 
the child is small and flexible, its expulsion in this 
way will be attended with comparatively little danger 
or difficulty. It is satisfactory to know, when the 
operation of turning is impracticable, (which must 
be a rare dilemma to one who understands his busi- 
ness,) that by the continued action of the uterus the 
child may possibly be born by that which is called 
its spontaneous evolution. 

* Vide Lond. Med. Jour., vol. v. 

t See a paper on this subject by Dr. Gooch, Med. Transactions 
of the College of Physicians, vol. vi., p. 230. 



228 ON PRETERNATURAL PRESENTATIONS. 



(d) PRESENTATION OF THE FUNIS. 



Before the membranes are ruptured, the funis, 
when it presents, feels like a ridge extending across the 
os uteri. You will, most probably, not recognise the 
funis in this stage ; but, when the membranes burst, 
the liquor amnii escapes, carrying with it the cord 
into the vagina. When this occurs, the labour is at- 
tended with danger to the child, but not to the 
mother ; for if the funis be compressed, the child 
suffers asphyxia. As the head descends, the circula- 
tion through the cord is impeded ; and if the child is 
long in the passage it will be still-born. How are 
we to act ? We are not justified in any measure, the 
object of which is to preserve the child, which will 
endanger the life of the mother. Do what you will, 
it is most probable the child will be lost. There are 
three modes of treatment proposed : first, to turn the 
child and deliver ; secondly, to return the funis, and 
keep it up, till the head descends, which will then 
effect the latter purpose ; thirdly, to apply the for- 
ceps. If we detect a presentation of the funis, when 
the os uteri is nearly dilated, the membranes entire, 
and the parts in a relaxed state, no one would 
here hesitate to turn and deliver, as it may be done 
with ease and safety ; and it will be best in this opera- 
tion to employ the left hand, as the feet will, most 
probably, be in the posterior part of the uterus. If 
you attempt to turn under less favourable circum- 
stances, nothing will be gained, for the delivery will 
be protracted, the life of the child consequently lost, 
and that of the mother placed in some danger. But 



PRESENTATION OF THE FUNIS. 229 

suppose the os uteri dilated, the membranes ruptured, 
and the head, with the funis before it, descending 
into the pelvis, if possible, endeavour to return the 
funis, and keep it up until the head descends beyond 
it by a continuance of the pains. You may push up 
the funis by the side of the head with your fingers ; 
but it requires to be kept there during several pains. 
I once had a funis presentation, when the life of the 
child was of great importance : I took a sponge and 
pushed it up after the cord into the uterus ; the sponge 
being of a large size kept up the cord, and the head 
descended properly. You may carry up the cord, 
and hang it on a limb if practicable. On the conti- 
nent they place the descending loop of the cord in a 
bag, in which it is pushed up beyond the head : and, 
when once up, the bag is too large to permit its de- 
scent. If the membranes are ruptured, and the head 
is descending rapidly, nothing can be done ; but if 
the head is low down, and descending slowly, apply 
the forceps immediately, if other circumstances are 
favourable. If the funis has been down so long as to 
have become flaccid and destitute of pulsation, the 
child is dead, and the labour is to be left to nature. 

There are three deviations from natural labour re- 
quiring the interference of art; the first is, that in 
which the child is properly placed in utero, but its 
expulsion is slow or impeded ; in the second, the 
child is placed unnaturally in utero ; in the third, 
the child is placed naturally, and no impediment 
may oppose its expulsion : yet there are some un- 
toward circumstances which render the labour com- 
plicated and dangerous. The two first deviations 
have been spoken of, and I next proceed to treat of 
the last. 



30 



230 OF COMPLICATED LABOUR. 



Section III. — Of Complicated Labour. 



(a) OF PUERPERAL CONVULSIONS. 



These may take place either during labour, or a 
few hours before labour commences ; after the labour 
has terminated or some months before its occurrence. 
The disease is characterized by insensibility, accom- 
panied by convulsions, in connection with the puer- 
peral state. The attack is preceded by symptoms 
of determination of blood to the brain; ^ts giddi- 
ness, headache, and singing in the ears ; sometimes 
sparks of fire seem to flash before the eyes, the mind 
wanders, and the vessels of the neck and face are 
turgid, the face is swollen, there is an irritation about 
the prsecordia, sickness, and pain in the stomach, 
making a combination of symptoms from which much 
danger is to be apprehended. The fit is often ac- 
companied with a slow pulse, which sometimes sinks 
as low as fifty in a minute just before its commence- 
ment. The convulsions are generally preceded by 
some, or all of these symptoms ; but they sometimes 
occur without being preceded by any of them. 
During the attack the eyes are turned upwards, the 
eyelids quiver, the mouth is drawn to one or other 
side, and twitched spasmodically ; frequently the 
tongue is thrust out, there is foaming at the mouth, 
and the countenance is frightfully distorted ; the re- 



OF PUERPERAL CONVULSIONS. 231 

spiration is performed with a hissing noise, and the 
whole body is violently convulsed. This state con- 
tinues for perhaps a few minutes, and then subsides : 
during the interval of the convulsions the patient is 
generally insensible, lying quiet and motionless in a 
state of stupor : sometimes she awakes from her 
stupor, and complains of pain in her head or spine, 
gets up in bed, and looks wildly about. If she is 
questioned, she shows no consciousness of what has 
occurred : after a time, which is uncertain, varying 
from a few minutes to two hours, the symptoms just 
mentioned are renewed. 

If convulsions take place before labour com- 
mences, though the patient be only in her sixth, 
seventh, or eighth month of pregnancy, it is generally 
found that contractions of the uterus begin, and labour 
quickly follows. These alarming symptoms may 
occur a few hours after the labour has commenced, 
which advances in consequence more rapidly : the 
child is very soon expelled, and apparently without 
pains. Sometimes, as soon as the child is born, and 
the uterus empty, the symptoms just described cease, 
and the patient goes on favourably. But this is not 
always the case ; experience shows that both the 
convulsions and the stupor may continue to succeed 
each other after the uterus is emptied, with little or 
no abatement. The convulsions may even com- 
mence after the labour is entirely over. This puer- 
peral disease differs from epilepsy at least inasmuch 
as it is excited by uterine irritation. Nothing has 
been found on examination after death, in some in- 
stances, to account for the fatal termination of this 
disease ; in other instances, there has been a con- 
siderable turgescence of the vessels of the brain, effu- 
sion or extravasation. 

There are two classes of females particularly liable 
to puerperal convulsions : — the plethoric and the 
irritable ; the irritability which disposes to them is 



232 OF COMPLICATED LABOUR. 

common among fashionable ladies, whose nervous 
systems are often very susceptible. Depressing pas- 
sions of the mind frequently produce this complaint: 
unmarried women, who have passed the latter months 
of pregnancy in solitude and wretchedness, are very 
likely to be attacked with it ; and it is found in lying- 
in-hospitals which admit unmarried women that a 
large proportion of cases of puerperal convulsions 
occur among females of this class. The conclusion 
to be drawn from this difference in the origin of the 
complaint is this : — Where there is preternatural 
susceptibility of the nervous system, we must, if 
possible, soothe it ; where there is plethora, we must 
empty the vessels. The remedies commonly re- 
commended are, — antispasmodics, bleeding, and de- 
livery. The first general experience shows to be 
useless. Hamilton says opi am is pernicious; bleeding 
is then our sheet-anchor, in whatever class of patients 
the disease may occur ; and to be efficacious, it must 
be employed boldly and speedily, and to a greater 
extent than is generally imagined. In a case of this 
kind the patient was bled with no apparent benefit, 
for the convulsions continued ; but during a fit, the 
bandage slipped from the arm, a great quantity of 
blood was lost, and the convulsions then ceased. 
This case is related by Dr. Denman ; .and it seems 
to be the first which suggested or confirmed the 
benefits to be derived from copious bleeding : he 
says fifty, sixty, or seventy ounces of blood, may be 
cautiously taken away. Dr. Hamilton says take 
away forty ounces at once ; and if in two hours the 
patient is not satisfactorily better, take away forty 
ounces more. When I heard Dr. Hamilton, in 
his lectures, deliver these instructions, I felt not a 
little astonished; but I can now conscientiously 
declare, that I have never had a patient die of puer- 
peral convulsions when the disease has been thus 
boldly treated; those who have died have been bled 



OF PUERPERAL CONVULSIONS. 233 

with a sparing hand, and to an insufficient amount. 
A little woman, eighteen years of age, of a spare 
habit, was seized with pain in her head, and trembling, 
on which she fell down senseless : I was sent for, and 
soon after my arrival she became convulsed. This 
was the first case of the kind I had ever seen ; and 
though the patient was not of a plethoric habit, I 
bled her to the amount of twenty ounces : before 
the bleeding was stopped she opened her eyes, and 
the convulsions ceased. I ordered her head to be 
shaved, directed cold applications to the scalp, and a 
dose of sulphate of magnesia, with infusion of senna, 
to be given every three hours till the bowels were 
well cleared. Notwithstanding the favourable im- 
pression produced by the bleeding, which was fol- 
lowed by the action of the purgative, in a short 
time the convulsions returned ; the bandage slipped 
off, and she lost about eight ounces of blood. The 
husband tied up' her arm, and in great haste ran for 
me without his hat and with his hands covered with 
blood: I went immediately, and took away twenty 
ounces of blood more, and the convulsions ceased, 
but still the patient remained insensible. I left her, 
directing the black dose to be continued : at ten 
o'clock at night I went to see her again, and just 
before my arrival she had a convulsive fit more 
violent than any preceding one. She had, since 
nine in the morning, lost forty-eight ounces of blood, 
and still remained much the same : I now again bled 
her to the amount of thirty ounces ; the convulsions 
ceased ; in the morning she was decidedly better ; in 
the course of the day uterine pains came on, she was 
delivered of a dead child, and gradually recovered. 
She had afterwards no recollection of the fits, or of 
any events which had occurred during some weeks 
previously. I could tire you with the relation of 
cases successfully treated in this manner, in which 



234 OF COMPLICATED LABOUR. 

we took care of the convulsions, and left the uterus 
to take care of itself. 

With regard to the third remedy, delivery, the 
introduction of the hand into the uterus, from the 
irritation which it occasions, does more harm than is 
compensated by the benefit derived from emptying 
the uterus; for although this is done, the convulsions 
often continue with undiminished frequency and 
violence, and the patient is also insensible during 
the absence of the convulsions. Though there may 
be no labour-pains, yet on examination you will often 
find the os uteri fully dilated, sometimes the mem- 
branes ruptured, and the head descended low into 
the pelvis : here, if you deliver, apply the forceps, 
but do not omit bleeding, and that copiously ; if you 
do, the delivery alone will not be sufficient to pre- 
serve the life of the patient. Give me the lancet, 
and deprive me of all other remedies, and I will do 
more good with it singly, than with all others, de- 
prived of this, put together. 

Puerperal convulsions may occur at the sixth or 
seventh month of utero-gestation : when they happen 
at this period they may be cured by judicious treat- 
ment, and the woman will sometimes go her full 
time ; but if she does, the child will generally be 
dead : the treatment is bleeding to a great amount, 
together with purgatives. In cases of puerperal con- 
vulsions, the os uteri being fully dilated, and the 
membranes entire, you may turn and deliver, as it 
may now be easily effected ; but if the os uteri is not 
already sufficiently dilated, the irritation occasioned 
by forcibly introducing the hand will be very dan- 
gerous. Deliver when circumstances permit this to 
be done with facility, but do not neglect bleeding. 
A pregnant woman was seized with convulsions ; 
the nurse, believing her not to be in labour, sent for 
an apothecary ; he thought the patient was in hys- 



OF PUERPEUAL CONVULSIONS. 235 

terics, and gave her asafcetida ; not getting better, 
another practitioner was sent for. On examining, 
he found the os uteri fully dilated, and the head low 
down in the pelvis : he applied the forceps and 
speedily delivered her, but the lancet was not used, 
and she died. Thus they took care of the uterus, 
and gave but little attention to the convulsions. A 
pregnant female, suffering from syphilis, was ad- 
mitted in St. Bartholomew's Hospital, and whilst 
there was attacked with puerperal convulsions : a 
student bled her to about twenty ounces : the con- 
vulsions recurring, he sent for me. I bled again, 
and took away thirty ounces more. I had my finger 
on her pulse, and felt it flutter as if she were about 
to faint ; she immediately opened her eyes, asked 
what we were doing, and fainted. It was curious to 
remark the change which took place in the brain ; 
passing from that of stupor, under which it was 
labouring during the interval of the convulsions, to 
that of its natural state, and immediately falling into 
that of syncope. The convulsions never returned, 
but the next day she was quite blind ; the pupil con- 
tracted and dilated on the admission and exclusion 
of light from a candle. The scalp having been 
previously shaved, I ordered her to be cupped 
on the head to the amount of twelve ounces ; this 
relieved her blindness. Some practitioners recom- 
mend emetics in this disease ; but it is very dif- 
ficult to get anything into the stomach. Dr. Den- 
man recommended sprinkling the face with cold 
water before the convulsions begin ; but the better 
way would be to place the head of the patient over a 
tub, and pour cold water upon it. Dr. Denman re- 
lates cases of sudden death from puerperal convul- 
sions, when no convulsion was present to occasion 
it ; the nature of the disease, I presume, was not in 
these cases correctly distinguished. After death 
from puerperal convulsions, he has found the auricles 



236 OF COMPLICATED LABOUR. 

and ventricles of the heart empty. He states that 
this disease is likely to be followed by peritonitis, 
and that we should watch our patient carefully for 
the first fortnight after delivery, in order to attack 
this complaint on its first approach. The truth of 
this remark is exemplified in the following case : — A 
lady had puerperal convulsions, the accoucheur who 
confined her called me in, and, by bleeding, the dis- 
ease was cured. About four days afterwards I was 
sent for again, not for anything my head could 
suggest, for the patient was moribund, but in order 
that my shoulders should bear the responsibility of 
the case. She had been attacked with peritonitis, 
her belly was much swollen and tense, and she very 
soon died ; the lancet had not been used, she had 
taken no purgative medicine, and had no evacuation 
for seventy-two hours. Camphor has been much 
recommended in puerperal convulsions, in doses of 
five or six grains every three or four hours. 



(b) OF HEMORRHAGE BEFORE THE BIRTH OF THE 

CHILD. 



The position of the child in utero may be natural, 
and there may be no impediment to its expulsion, 
but the life of the patient may be endangered by 
uterine haemorrhage. This seldom occurs during 
the second stage of labour ; but in the first, when 
the os uteri is but little dilated, it is not uncommon. 
A disturbed state of the circulation, accompanied with 
a rapid pulse and heat of skin, as in abortion, may 
occasion uterine haemorrhage ; and, without any 
other symptoms, the blood may gush copiously 
from the vagina. Mechanical injury, as a blow on 
the belly, or side, or a sudden concussion of the body, 



OF HEMORRHAGE BEFORE BIRTH OF CHILD. 237 

violent exertion, or great mental emotion may oc- 
casion haemorrhage by detaching a portion of the 
placenta from the surface of the uterus. Sometimes 
the foetus dies towards the latter period of gestation, 
and still remains in the uterus for several weeks, 
when the attachment of the placenta becomes loosened, 
and its separation is followed by haemorrhage. The 
expulsion of children that have been manifestly dead 
some time, is generally preceded by haemorrhage. 
But now and then cases of haemorrhage occur with- 
out any apparent cause ; probably for the reason 
that the adhesion of the placenta to the uterus is 
preternaturally slight. 

In general the placenta is attached to the fundus 
uteri, or very near it, but it is sometimes placed over 
the os uteri. During the first four months of utero- 
gestation the cervical portion of the uterus suffers 
no change, and it is impossible before the expiration 
of that time to know that a woman is pregnant. 
About the fifth month the neck of the uterus begins 
to dilate, and at the eighth it is wholly obliterated : 
as this change of the cervical portion of the uterus 
is going on, some of the vessels of the placenta are 
separated from it, and haemorrhage is the conse- 
quence ; this therefore may occur at any period after 
the dilatation of the cervical portion of the uterus 
has commenced. Sometimes haemorrhage does not 
occur until within a few days of labour; at others, 
not until within a few hours ; but if the placenta 
is attached over the os uteri, when labour commences 
haemorrhage must ensue. It may also occur from 
the separation of the placenta, when placed naturally 
at the fundus uteri ; it is then called accidental 
haemorrhage ; but when the placenta is implanted 
over the os uteri, inevitable haemorrhage. The 
haemorrhage may come on, and cease for days, 
and then recur, and again cease : at length the 
patient's constitution suffers from loss of blood, she 

31 



23g OF COMPLICATED LABOUR. 

becomes pale, faint, and dies from exhaustion ; the 
uterus not having power to expel the child, Demg as 
it were paralysed by the previous loss of blood. In 
some instances, uterine pains come on, the os tmcae 
becomes dilated, the membranes burst, the ^ 1( l uor 
amnii escapes, and the hemorrhage ceases, by the 
contraction of the uterus on the child which is ex- 
pelled naturally. In other cases the hemorrhage 
has continued a long time, the patient's constitution 
has suffered in consequence, labour-pains come on ; 
and the child is expelled, but only for the woman to 
die ; for on the separation of the remainder of the 
placenta, the gush of blood which then takes place 
is often sufficient to kill her ;* or, if she survives, it 
will probably be but for a few months. Though 
patients do not always die if left to nature, yet she 
is not in these cases a trust-worthy practitioner. 

When hcemorrhage from the uterus is moderate 
it may sometimes be sufficient to lay the patient in 
the horizontal posture on a sofa, and keep the cir- 
culation tranquil by cold drinks, as tea, milk and 
water, gruel, &c, abstinence from animal food and 
fermented liquors, together with gentle aperients 
and bleeding if indicated by the state of the pulse. 
Some recommend the mineral acids, with infusion 
of roses and sulphate of magnesia; this is a good 
mixture and may be given with advantage : but the 
best medicine in these cases that I know of is ten or 
fifteen grains of the nitrate of potash every four or 
five hours, plunged into cold water, and immediately 

* In a few extreme rases of uterine haemorrhage, blood has been 
transfused from one subject to another with success by Dr. Blun- 
ne!l. (See his experiments and cases in the Med. Chir. Transac- 
tions, vols. 9 & 10; see also Lancet for January 3d 1829 ) 

The first public experiment of the transfusion of blood was by 
Dr. Lower at Oxford, in 1665; and it was subsequently per- 
formed in France on the human subject, without any very en- 

Z^M Zl?* U *' ° f fi " f bJ r tS ° n Wh ° m h WaS Permed 
by M. Denis, three recovered and two died ; when the perform- 
ance of it was prohibited under the penalty of imprisonment. 



OF HEMORRHAGE BEFORE BIRTH OF CHILD. 239 

swallowed, so that its solution may take place in the 
stomach ; I have more faith in this than in any other 
remedy of the kind, but how it acts I know not. 
By this mode of treatment the haemorrhage may 
cease, the patient go her full time, and the labour 
may terminate favourably. But the haemorrhage 
sometimes recurs, of which there is always a proba- 
bility as long as the uterus continues distended. 
Here experience shows that emptying the uterus of 
its contents is the most effectual styptic, and the 
only one to be relied on in extreme cases. How will 
you do it? There are two methods proposed; one 
is to turn the child, and finish the labour at once ; 
the other, to rupture the membranes with your finger, 
or a catheter, and let off the liquor amnn, by which 
the distention is diminished : the uterus now contracts 
on the child, and the haemorrhage ceases ; after some 
time, labour-pains come on, and the child is expelled. 
Suppose, says Rigby in his work, which is the best 
on this subject, you are called to a woman suffering 
from haemorrhage before labour commences ; you 
make an examination by which you will ascertain 
the cause of the haemorrhage. If the placenta is 
attached over the os uteri, though the haemorrhage 
may have ceased, it will inevitably recur on the dila- 
tation of the os uteri, and that recurrence may kill 
the patient ; therefore, whenever I find the placenta 
implanted over the os uteri, I cannot trust to nature, 
and I introduce my hand, as soon as I can do it 
without much difficulty, turn and deliver. But if 
on examining I feel only the bald membranes, and 
no placenta over the orifice of the uterus, I then 
puncture them and let out the liquor amnii, and the 
haemorrhage ceases ; I keep the patient cool, and in 
a recumbent position, and watch her ; soon after, 
labour comes on in a regular manner. If the placenta 
be implanted over the os uteri, either wholly, or in 
part, you recognise it by the feel : it is a spongy 
lobulated cake. A person ought to have a finger and 






240 OF COMPLICATED LABOUR. 

half to feel the os uteri, in these cases, by the common 
method of examination ; for the uterus is so high up 
that one of ordinary length will not reach it; in 
common labour the uterus has descended low into 
the pelvis, and can be reached by the finger from the 
os externum ; but in these cases you must introduce 
the whole hand into the vagina, and then pass one 
finger into the os uteri, and ascertain whether the 
presentation is that of the bald "membranes, or of this 
spongy lobulated cake. If the latter, we know that 
the haemorrhage will certainly be renewed ; and 
therefore the sooner the delivery can be safely ac- 
complished by turning, the better. Delivery, in 
cases of uterine haemorrhage, may be attempted too 
soon, or delayed too long. It will be too soon if the 
hand is forced through the os uteri when it is but 
little dilated, which may occasion- a fatal laceration; 
and it will be delayed too long, if so much blood 
be already lost that death may be the consequence, 
either immediately, or in a few hours after delivery. 
I know three medical men who had each met with 
cases of haemorrhage preceding the birth of the child, 
and they lost their patients by neglecting to deliver 
sufficiently early. They therefore resolved that this 
should not again happen, and falling into the opposite 
extreme in the next cases they met with, they intro- 
duced their hands at once upon the first occurrence 
of haemorrhage, and killed their patients by the vio- 
lence used in dilating the os uteri. What is the best 
rule of practice in those cases of uterine haemorrhage 
in which, with a common presentation, its recurrence 
may endanger the life of the patient? As soon as your 
hand will pass through the os uteri without difficulty, 
the sooner you deliver the better. In doing this pro- 
ceed with caution; having introduced the hand into 
the vagina, pass one finger first through the os uteri, 
and then another, till the tips of all the fingers, form- 
ing a cone, are within the os uteri ; next try gently 
to pass on the hand ; if the os uteri gripes it like a 



OF HEMORRHAGE BEFORE BIRTH OF CHILD. 241 

cord, do not force your hand forward, but wait a 
little ; a pain comes on, and out gushes a little 
blood; during this time the orifice is becoming 
more dilated and relaxed ; if it yields readily, finish 
the introduction of your hand, turn and deliver. 

But suppose on examination the placenta is found 
attached over the os uteri ? If the symptoms will 
allow your waiting an hour or two, the os uteri 
gradually dilating and relaxing, you will then gener- 
ally be able to introduce your hand without difficulty. 
Which hand will you use ? There are eighty 
chances to one in favour of the child's being naturally 
placed, with its back towards its mother's belly, and 
its belly towards its mother's back ; if the belly is 
towards the posterior surface of the uterus, there also 
you will find its feet. Having placed the patient 
across the bed, with her breech close to its edge, pass 
up your left hand into the posterior part of the uterus, 
and the feet will fall within its grasp. Will you pass 
your hand through the placenta, or separate a portion 
of it from the uterus, to enable you to rupture the 
membranes ? In general the placenta does not 
wholly cover the os uteri, and by passing your finger 
round it you will discover the bald membranes in 
some part of its circumference, through which, of 
course, you will introduce your hand. But if the 
placenta covers the os uteri entirely, the hand may 
be passed through it, which does not greatly increase 
the haemorrhage ; this method, how r ever, is not free 
from objections, for the passage of the head of the 
child through this opening will be attended with 
some difficulty. You also pass your hand through 
that which serves the purpose of lungs to the foetus : 
for these reasons, we must rupture the membranes, 
if possible, by introducing our hand at the side of 
the placenta, and rend them " fore and aft," for this 
opening should be perfectly free. The hand being 
fairly introduced into the uterus, lay hold of the feet, 
or of one foot, taking care not to mistake the hand 



242 OF COMPLICATED LABOUR. 

for the foot. If I cannot readily find both feet, I 
bring down one, and make it half foot and half 
breech presentation, which is not particularly disad- 
vantageous, for it causes the os uteri to be more 
freely dilated by the time the head has to pass 
through it. As soon as the feet are brought into the 
vagina, the liquor amnii escapes with a gush, and 
the flooding generally ceases. I now leave nature 
to expel as much as she can of the child, in order to 
insure the contraction of the uterus, which I en- 
deavour to promote by friction on the abdomen. 
When the umbilicus is born, the life of the child 
will be additionally endangered from pressure on the 
funis ; I therefore proceed to extract without delay 
in the manner formerly described when speaking of 
breech and feet presentations. Young practitioners 
are often afraid to attack these cases with the prompti- 
tude their urgency demands, but allow a patient to 
go on flooding nearly to exhaustion, when, if she does 
not die during the delivery, or immediately after it, 
her ultimate recovery will be doubtful or almost 
impossible. The operation of turning before the 
liquor amnii has escaped, is one of the most easy in 
the practice of midwifery ; and in the cases of which 
we are now treating, it must be done, otherwise the 
patient will die. 

I was consulted in a case of hemorrhage which 
had continued irregularly four or five days ; I found 
the patient with a bleached face, and greatly reduced 
in constitution. On examination I perceived that 
the placenta was over the os uteri. It was the first 
case of the kind I ever met with ; I was afraid of 
pushing my hand into the uterus, and only ordered 
her some acidulated infusion of roses, perfect rest, 
and cold drinks : this was attended with no benefit ; 
and thus it went on four or five days, when I was 
again called to her, and again prescribed a similar 
medicine, differing only in colour. I directed them 
to send for me if she became worse, vowing if again 



OF HEMORRHAGE BEFORE BIRTH OF CHILD. 243 

summoned I would turn and deliver. I left her in 
the evening and went home to bed early. About 
seven o'clock in the morning there was a violent 
ringing at the bell : my servant came up saying, 
Mrs. Beale was dying. I ordered my horse, having 
five miles to ride ; dressed as quickly as possible, 
and proceeded to the scene of action with all speed. 
When I came to the village, not far from the house 
of my patient, I saw a posse of old women standing 
in the road, and guessed at the subject of conversa- 
tion. On coming up to them, I said, " Good morn- 
ing; what o'clock is it?" The answer I received 
from one of them was, " Never mind what o'clock 
'tis; Dame Beale is dead by this time." When I 
came to the door I was saluted by the blubbering of 
the woman, husband and brother; I rushed up 
stairs, and directly passed my hand up the vagina ; 
I thought it was in the uterus ; but it was only in 
the portico, the entrance into the sanctuary ; I then 
passed my hand on through the os tineas into the 
uterus. I used my left hand and came directly on 
the feet, which were in the posterior part of the 
uterus ; I grasped them, drew them down, and de- 
livered with the greatest facility. This being done, 
I found it was a twin case. I immediately intro- 
duced my hand again, ruptured the membranes of 
the second ovum, and delivered : this was performed 
with equal ease, the uterus contracted, the placenta 
came away in half an hour, and she recovered. Six 
weeks afterwards as I passed by, I saw her at the 
garden gate feeding her ducks. In a case of pla- 
centa presentation the woman should not be left, for, 
before you have been absent a quarter of an hour, 
the haemorrhage may be renewed profusely. You 
must wait the proper time for the delivery, and 
amuse yourself with books, &c, in an adjoining 
room, in order that you may be ready when wanted. 
In these cases it is sometimes difficult to detect the 



244 OF COMPLICATED LABOUR. 

presentation. I was called to the wife of an opulent 
person in the city, who was flooding : on examination 
a large clot of blood, which was in the way, pre- 
vented my ascertaining whether the placenta or the 
membranes were over the os uteri. I requested a 
consultation, and sent for Dr. Haighton, who felt 
the same doubt as to the nature of the presentation ; 
but it was agreed to pass the hand on, remove the 
coagulum, and, if possible, to rupture the membranes, 
as her constitution was already affected by the loss 
of blood. I discovered the membranes, and with my 
nail previously notched, sawed them right and left ; 
out gushed the liquor amnii ; the haemorrhage im- 
mediately ceased, and did not return. In a few 
hours uterine pains came on, and the child was ex- 
pelled naturally. 

Sometimes after delivery so much blood has been 
lost, that though the haemorrhage may have ceased, 
the patient's life is in extreme danger, and can be 
preserved only by the most persevering and judicious 
employment of stimuli. No man does his duty unless 
he watches his patient, and delivers her before she 
has lost so much blood as seriously to affect her 
constitution. These cases are very deceptive ; the 
haemorrhage may cease and return, and may go on 
ceasing and returning alternately, till the constitution 
suffers a fatal exhaustion. But before proceeding 
to deliver, it is necessary to wait till the constitution 
is slightly affected by the loss of blood, when the 
introduction of the hand will be rendered compara- 
tively easy : if the os uteri is still undilated, and not 
relaxed, the introduction of the hand will be attended 
with so much violence, that a fatal laceration may 
be the consequence. But haemorrhage tends to 
relax the fibres of the uterus ; try, therefore, carefully 
to introduce your hand ; if this is much resisted, it 
will be proper to wait a little; if the parts yield 
readily, this is the time to turn and deliver if it should 



PLURALITY OF CHILDREN. 245 

be found requisite. If the placenta is not attached 
to the os uteri ; if you feel the membranes and the 
hard head behind them, rupture them, and allow 
the water to flow ; the uterus immediately contracts, 
the haemorrhage ceases, and in a few hours labour 
generally commences. It is possible the haemor- 
rhage may continue after the membranes are rup- 
tured : this, however, never occurred in my prac- 
tice, or in that of Mr. Rigby; but if the haemor- 
rhage does continue, and the life of the patient is 
endangered by it, you must then turn and deliver 
under the disadvantage of a contracted uterus. 

In conclusion, I must impress upon you the rule, 
that when the placenta is attached over the os uteri, 
you must turn and deliver ; and you must do this 
before the constitution of your patient suffers from 
too lono- a continuance of haemorrhage. If in a case 
of flooding before delivery, the presentation is that 
of the membranes, and not that of the placenta, 
rupture the membranes and allow the liquor amnii 
to escape ; the uterus will contract upon the child, 
and the haemorrhage will cease ; but if the placenta 
presents, you have then no choice ; you must turn 
and deliver as soon as the parts are sufficiently 
relaxed to permit this to be done without violence. 



(c) PLURALITY OF CHILDREN. 



Twin cases are calculated to occur once in about 
seventy labours. The uterus very seldom contains 
more than two children, though in very rare instances 
it may contain three, four, or even five.* Mr. Rigby, 

* In Phil. Trans, (vol. lxxvii., p. 344,) there are some re- 
markable cases of plurality of children communicated by Dr. 
Gartshore. 

32 






246 0F COMPLICATED LABOUR. 

at the age of eighty, was the father of four children 
at one birth. 

In the first place, how is a twin case to be ascer- 
tained ? In the second, when ascertained, what kind 
of management does it require ? It is impossible to 
ascertain the existence of twins before the birth of 
the first child. After the birth of the child, in every 
case to which you are called, you should place your 
hand on the abdomen of the mother ; if there is not 
another child you will feel, just above the pubes, a 
hard, round ball, filling the hypogastric region; this 
is the contracted uterus, and above this the abdomen 
is flaccid, which is an infallible proof that there is 
not another child. But when another child is still 
in the uterus, the abdomen will be felt to be as hard, 
and nearly as large as before the delivery of the first. 
But it sometimes happens that women are pregnant 
while suffering from ovarian dropsy, the ovary and 
the uterus, side by side, go on enlarging together. 
In this case the belly of the patient, after the deli- 
very of the child, is still large and hard ; the external 
examination therefore in this state of the abdomen, 
is not sufficient, the hand must be introduced into 
the vagina, and the fingers partially into the uterus; 
if there is another child you will feel the membranes 
and the presenting part of the child behind them. 
The patient may be surprised at the introduction of 
your hand, but any nervous reluctance to this on your 
own part must.be overcome, for sometimes twenty- 
four hours, nay, three days, may elapse before the 
action of the uterus will be resumed; and if it should 
prove that you have left your patient while a child 
remained undelivered, you will be laughed at as an 
ignorant practitioner. In the first twin case I ever 
met with, I failed to discover the existence of a second 
child : the placenta not coming away, I called in a 
friend, who soon discovered the mistake ; although 
I did not leave my patient, I did not escape ridi- 
cule. 



PLURALITY OF CHILDREN. 247 

Supposing the existence of twins to be ascertained, 
what is to be done ? You must not leave your pa- 
tient until she is delivered. You must never attempt 
to remove the placenta until the second child is born; 
this indeed cannot be done without difficulty ; but if 
it is done you will manufacture a most serious hse- 
morrhage. The uterus is often tardy in resuming 
its efforts for the delivery of the second child. The 
first object is to excite the uterus to the expulsion of 
the child by its own powers. If this cannot be done, 
it will be necessary to turn and deliver. How do 
you excite the action of the uterus? The membranes 
are to be ruptured immediately on the delivery of the 
first child : the liquor amnii escaping, the uterus will 
be diminished in size; and, after an interval varying 
from half an hour to two hours, pains will again come 
on ; during this time, we must endeavour to excite 
the action of the uterus by occasional pressure and 
friction on the abdomen. Be prepared for the occur- 
rence of haemorrhage in these cases, and manage the 
labour so that this danger may be guarded against 
by all the natural powers. Make the uterus, if pos- 
sible, expel the head, shoulders, body, and limbs of 
the child. Thus you will have the fundus uteri 
close on the heels of the child : irregular contraction 
of the uterus therefore (which is most frequently 
owing to bad practice) cannot take place. I have 
compared notes with those who make it a rule to ex- 
tract the second child immediately after the birth of 
the first, and I find that they are often embarrassed 
by irregular contraction of the uterus and haemor- 
rhage ; neither of which will happen if the uterus is 
left to expel every part of the child. With respect 
to the position of the second child, if the presenta- 
tion is not natural, the same mode of treatment will 
be required as if there were only one. 

If in two hours after rupturing the membranes, the 
child does not advance, or the pains return, you ma}' 
then turn and deliver, which will be done with ease, 



248 0F COMPLICATED LABOUR. 

for, as the os uteri is inactive, no resistance will be 
offered by its contractions. Having turned the child, 
its extraction must be as deliberate as possible till the 
umbilical cord becomes liable to pressure ; the child 
is then in danger of asphyxia, and you must proceed 
as formerly recommended in feet and breech presen- 
tations. When the second child is born, feel for a 
third, and so on, until you are quite satisfied that no 
other remains. 

With respect to the management of the placenta 
in these cases, their removal is not to be attempted 
until it is ascertained that no child is left in the uterus. 
This point being settled, wait a little and use fric- 
tion on the abdomen. When on examination per 
vaginam you can feel the placenta resting on the os 
uteri, and the uterus, by pressure externally, con- 
tracted into a ball at the bottom of the belly, you 
may then take hold of all the cords, and gradually 
extract, as in a common labour. As each child is 
born, two ligatures must be applied to the umbilical 
cord, which is to be divided between them. 



(d) RUPTURE OF THE UTERUS. 

The uterus is sometimes ruptured by extraneous 
violence, and sometimes spontaneously by its own 
action; however it may occur, it is an injury of the 
most dangerous character. The cervix uteri is so 
much more disposed to laceration than any other 
part, that four times out of five, when spontaneously 
produced, it occurs in this place, just at the connec- 
tion of the uterus with the vagina. The vagina 
may also participate in the laceration. 

When laceration has taken place to a certain ex- 
tent, the symptoms are the receding of the present- 



RUPTURE OF THE UTERUS. 249 

ing part, external discharge of coagulated blood, 
sudden or gradual cessation of the pains, fainting, 
trembling, with a sense of sinking ; the pulse is small 
and rapid, the countenance altered and pallid ; there 
is sickness, and the fluids vomited are sometimes of 
a dark colour. When these symptoms appear, there 
is little doubt but laceration of the uterus has taken 
place, and previously to their occurrence, in addition 
to violent uterine action, which makes but little im- 
pression on the child, the abdomen feels hard like a 
cramped limb, and the patient complains of fixed 
pain, generally above the pubes, with a sense of rend- 
ing. When the head is low down in the pelvis, lace- 
ration may occur without a receding of the present- 
ing part; it is then more difficult to detect. But 
whether you know it or not, the symptoms just men- 
tioned are sufficient to warrant the application of the 
forceps when practicable. Laceration of the uterus 
may be occasioned by the forcible introduction of the 
hand in the und dated state of the os tincse, or by 
improper violence used in turning the child when the 
uterus is contracted, or by the unskilful management 
of instruments; on all these points I have already 
cautioned you. It is a prevalent notion, that a healthy 
uterus may be lacerated by a forcible or irregular 
contraction against any hard, unyielding substance, 
such as a joint or bone of a child, or the linea ilio- 
pectinea in the pelvis of the mother when this forms 
an unusual projection. The uterus may certainly be 
lacerated by its own action ; but I doubt whether 
this would occur unless the parietes of the uterus 
were unusually thin, or unless there was, at some 
part, an alteration of its texture. The supposition 
of some change of this kind has been confirmed by 
examinations after death ; in some instances the 
change of texture predisposing to laceration has been 
such that this has occurred where the pains have 
been of the weakest kind. Dr. Denman relates a 



250 OF COMPLICATED LABOUR. 

case of this kind, when after the most trifling pains 
on passing up his hand it came in contact with the 
bowels. Rupture of the uterus has been found after 
death to have been occasioned by sloughing. A mid- 
wife was called to a woman in labour, but finding 
the pains very feeble, and at long intervals, left her 
after remaining with her a few hours. Slight pains 
continued to recur; and about one o'clock in the 
morning blood was discharged from the vagina, and 
the symptoms in other respects became alarming. 
A medical man was sent for, who said they were mis- 
taken in supposing the labour was making any pro- 
gress ; the pains had entirely ceased, and he believed, 
from the convulsed and laborious breathing of the 
woman, that she was dying of phthisis pulmonalis. 
After this medical gentleman had left her I was sent 
for, but she died an hour before I arrived. The belly 
of the patient was still warm, and I could distinctly 
perceive by the touch the head and limbs of the 
child with the intervention only of the parietes of 
the abdomen. Coupling this with the account of the 
midwife of the symptoms preceding her death, I 
wrote to the medical man who had seen her, ex- 
pressing my conviction that it was a case of rupture 
of the uterus, and apprising him of my intention to 
examine the body at a specified time. Mr. Hodgson 
and this medical man were present, and on cutting 
through the abdominal parietes, the child was found 
in the cavity of the peritoneum, among the intestines. 
The laceration was in the posterior part of the ute- 
rus, which was in a sloughy state, and thin and livid 
in the vicinity of the laceration. These are deplo- 
rable cases, but while there is life there is hope : 
some cases of rupture of the uterus have done well.* 

* See Lond. Med. and Physical Journal, vol. xix., p. 209 ; 
also a case of separation of a portion of the uterus during - severe 
labour, communicated by Dr. Merriman, Med. Chirurgical 
Transactions, vol. xi., p. 392; and, in vol.xiii., cases of rupture 
of the uterus successfully treated by Mr. Birch and Dr. Smith. 



RUPTURE OF THE UTERUS. 251 

The bowels and peritoneum inflame, and there is 
some haemorrhage from the lacerated part of the ute- 
rus : the danger is enhanced by these symptoms ; 
but, independently of them, the mere laceration of 
the uterus is sufficient to produce a feeble, rapid, 
and tremulous pulse, great disorder of the constitu- 
tion, quick and anxious respiration, delirium, and 
death. 

Can you anticipate the occurrence of a laceration ? 
If so, can you prevent it ? and in what manner ? Dr. 
Hamilton says it is preceded by hard and cramped 
state of the belly, by incessant and agonising pain, 
or if there is any interval it is extremely short, and 
during it a sense of tightness, straining, and rending 
is felt internally in some part of the abdomen ; that 
from these symptoms you may anticipate laceration, 
which is to be prevented by paralysing the uterus, 
and thus subduing its inordinate action. Bleeding 
must therefore be resorted to till fainting is produced, 
when the action of the uterus will be greatly dimi- 
nished, if it is not altogether suspended : you must 
then extract the child, but this will depend on the 
stage of the labour. If the os uteri is not fully di- 
lated you must bleed, and wait a little, and then apply 
the forceps if the head is within their reach. If the 
head is too high up for the forceps, we should hesi- 
tate before resorting to the perforator, for the symp- 
toms may be too equivocal to justify the destruction 
of the child ; if, however, the necessity of a speedy 
delivery is decided on, we have under these circum- 
stances no other resource. Laceration most com- 
monly occurs when the pains are slight, and the ac- 
tion of the uterus weak. If laceration has taken 
place, and the head or presenting part is receding, 
you must deliver as soon as possible by searching for 
and bringing down the feet ; or apply the forceps if 
the head be within their reach. Dr. Douglas met 
with a case of laceration of the uterus : on intro- 



252 OF COMPLICATED LABOUR. 

ducing his hand he found that it passed into the bag of 
the peritoneum ; at first he knew not where it went, 
he searched for the feet, and having found them, he 
extracted the child carefully, and afterwards the pla- 
centa : this woman recovered with very little more 
suffering than that of some pains in the belly. Dr. 
Osborne saw this patient with Dr. Douglas on the 
third day after her delivery, when her pulse was a 
hundred, and in six weeks she was perfectly well. 
This woman again became pregnant, and was attended 
in her labour both by Dr. Douglas and Dr. Denman; 
fearing another laceration of the uterus, Dr. Douglas 
turned and delivered, and while turning he felt for 
the cicatrix of the former laceration, but could not 
discover it. She afterwards became pregnant again, 
and the labour was accomplished naturally. A ter- 
mination so favourable as was exemplified in this 
case, must, however, be considered as a rare exception. 
The process of labour has been considered in all 
its varieties. We are now to speak of the treatment 
of women after delivery. 






MANAGEMENT OF WOMEN AFTER DELIVERY. 253 



LECTURE THE FIFTH. 



ON THE GENERAL MANAGEMENT OF WOMEN AFTER DE- 
LIVERY, AND ON THE TREATMENT OF THE COMMON 
AFFECTIONS INCIDENT TO THE PUERPERAL STATE. 



Section I. — General Management, etc. 



After the birth of the child, and the removal of 
the placenta, place your hand on the abdomen, above 
the pubes, to ascertain whether the uterus is con- 
tracted ; clear away the coagula, and apply a warm 
dry napkin closely to the pudenda; a bandage of con- 
siderable width should also be applied round the ab- 
domen, not so tight as to produce any uneasiness, 
but sufficiently so to give a comfortable degree of 
support; which will favour the contraction of the 
uterus, and, consequently, tend to prevent haemor- 
rhage. The curtains of the bed should be closed, 
and, as premature disturbance may produce syncope 
or haemorrhage, the patient should remain at rest, 
without any change of position, for two hours. Some 
person should, however, remain in the room with her, 
and it should be ascertained, by an occasional inquiry 
or examination, that there is no flooding. No prac- 
titioner should take leave of his patient in less than 
an hour after the delivery of the placenta : this may 
be occasionally felt as a great sacrifice of time ; but 

33 



254 MANAGEMENT OF WOMEN AFTER DELIVERY. 

if this rule is not observed, a practitioner may some- 
times lose a patient by flooding, whose life he might 
have preserved, if he had quitted her less hastily. 
After her delivery, the patient may be allowed a lit- 
tle tepid gruel ; and when two hours have elapsed, 
the nurse should be directed to make such alterations 
in her dress as may be necessary to her comfort; 
during labour, the round flannel petticoat is inconve- 
nient; it is in the w T ay; and prevents, in some mea- 
sure, your giving proper support to the perinseum : 
a shift of considerably less than the usual length is 
much better. Whatever change is made in the 
dress, &c, of the patient, the recumbent position must 
be strictly preserved : she must not, on any pretext, be 
got upright for one moment. You make your first 
visit after delivery, according to circumstances, 
either in twelve or twenty-four hours, when you may 
expect your patient's pulse to be soft and tranquil. 
Ascertain from the nurse whether the accustomed 
discharge goes on favourably, and also whether the 
urine has been freely passed ; a retention of the latter 
is sometimes the effect of pressure against the ure- 
thra during the passage of the head of the child. 
This trifling impediment is frequently overcome 
during the action of a dose of castor oil, or other 
aperient; but should the patient be suffering the 
pain and irritation of a distended bladder, the intro- 
duction of the catheter must not be delayed : a brisk 
aperient should be given, and warm fomentations 
employed above the pubes. If the retention of urine 
should continue, the bladder must be emptied by 
the catheter as often as circumstances require. 



AFTER-PAINS. 255 



Section II. — After-pains. 



The complete contraction of the uterus does not, 
after delivery, take place at once, but by several ef- 
forts occurring at irregular intervals, and attended 
with pains of a lesser degree, but similar to those of 
labour ; these pains affect the back, belly, and thighs : 
but they are not accompanied with heat of skin, or 
disturbance of the circulation. After a first labour, 
the patient does not, in general, suffer so much from 
these pains as in subsequent labours. These pains 
are connected with a process of nature which should 
not be materially checked ; it is as well, however, to 
direct some anodyne draughts, consisting of two 
drachms of syrup of poppies in an ounce and a half 
of almond emulsion ; one of which might be taken if 
these pains are severe, and repeated, if they are not 
mitigated, every three or four hours. If the pains 
are trifling, it is better to dispense with the anodyne ; 
if they are troublesome, give no more of it than is 
necessary. If there is great irritability of the constitu- 
tion, and the patient's suffering from after-pains is 
unusually severe, it may be necessary to add to the 
above draught twenty drops of the tincture of opium. 



256 MANAGEMENT OF WOMEN AFTER DELIVERY. 



Section III. — Diet. 



During the first three days after delivery, the 
breakfast, dinner, and supper of the patient must con- 
sist of gruel and barley-water ; no solid meat, no 
broth, no fermented liquor. The patient must be 
kept quiet and cool ; no gossips are to be admitted : 
the husband must stand as sentinel to exclude all in- 
truders; no stimulating food must be given, for the 
constitution is now very easily excited ; this irrita- 
bility usually subsides in about three days. 

When is the child to be applied to the breast? 
For the first twelve hours there is no secretion of 
milk ; at about the end of this time a pricking sen- 
sation is felt in the breasts, which become rather 
full, and in about twenty-four hours the tide comes 
in. The system is considerably disturbed for some 
little time after a severe and protracted labour, and 
the milk secreted during this disturbance will proba- 
bly disorder the child ; therefore, right or wrong, 
under such circumstances, I never allow the child 
to be put to the breast till the mother has had some 
tranquil sleep. If the patient is delivered in the 
evening, and has slept during the night, the child 
may be put to the breast in the morning, that is, 
about twelve hours after the delivery ; and this 
should be done whether there is milk or not, for the 
sucking of the child excites the breast to secretion ; 
after waiting twelve hours, if the mother has not 
slept, the child may be put to the breast in order to 



DIET. 257 

excite secretion, but it is better still to wait until the 
mother has slept before the child is allowed to suck 
in an effectual manner. The third, fourth, or fifth 
day may pass, and the bowels of the patient may 
not be relieved by any evacuation : there is, during 
pregnancy, a great disposition to costiveness, and 
women who in this state neglect to take aperients, 
fall into labour with loaded ■ bowels. This, indeed, 
is so commonly the case, that Dr. Denman thought 
this state, from its regularity, a natural one, and on 
this ground abstained from any interference. On 
the third day I prescribe an active purge, whether 
the patient has had an evacuation or not ; for by a 
spontaneous evacuation the bowels are still but par- 
tially relieved ; castor oil should be a standing dish 
in the lying-in room, of which a large table-spoonful 
must be given on the third day after delivery, not in 
brandy, but in milk or coffee. Fill two-thirds of a 
wine-glass with milk or coffee, and upon this pour a 
table-spoonful of castor oil, which, forming a globe in 
the centre of the other fluid, may be swallowed with- 
out being tasted; this dose is generally sufficient; 
but if in six or eight hours it does not operate, give 
a desert-spoonful more ; if the second dose does not 
succeed, a glyster should be administered. Some 
patients very much dislike castor oil ; I then indulge 
them with the following black dose : r. Infus. senna? 
§ii., magnes. sulph. 5iii-, manna 5ii-> tr. jalapse 3i- 5 f. 
haustus; if this draught does not operate in a few 
hours, rather a weaker dose of the same kind should 
be repeated. The aperient should be such as to in- 
sure four or five motions on the third day after de- 
livery. On the fourth day, provided all be well, the 
patient may take a little boiled chicken, or mutton, 
or broth ; after the fifth day has passed, the patient 
should be quite well, and your subsequent visits are 
merely for the purpose of watching her. Women 
now generally wish for wine or porter ; I usually 



258 MANAGEMENT OF WOMEN AFTER DELIVERY. 

mix good barley-water with milk (equal parts) mak- 
ing barley-gruel, and, presenting this beverage, I tell 
them, " This is your wine and your porter, too ; it will 
relieve your thirst and sinking at the stomach, and 
will manufacture milk better than anything else." 

The longer you keep the patient in the recumbent 
posture the better, as procidentia uteri will be less 
likely to occur ; but about the fifth or sixth day, she 
had better be removed from between the warm 
blankets, the heat of which is relaxing ; she must 
not, however, be allowed to sit upright, but must lie 
on a couch, or sofa, or on the outside of the bed ; the 
trunk must be kept in the horizontal position ; but 
it is difficult to make patients preserve this posture ; 
they think, as long as their legs are kept up, it is no 
matter where the trunk is. I care not a straw where 
their legs are, provided the trunk is horizontal; for 
three weeks after delivery, the patient should be 
kept chiefly in the recumbent posture. The uterus 
was very recently of large size ; an immense sac : 
the consequence of sitting up soon after delivery, 
with a heavy uterus suspended in a flaccid abdomen, 
will be a prolapsus of this organ. Patients in the 
higher classes, who can preserve the recumbent po- 
sition for any length of time, seldom suffer prociden- 
tia uteri, but it is extremely common among the 
poorer classes, who get up very soon after delivery, 
and fatigue themselves with their domestic concerns. 
The seventh, eighth, and ninth days pass, and your 
patient continues quite well ; during the first four 
days you see her every day ; for five days after, every 
second day ; the ninth day is esteemed a very criti- 
cal one, not that it is more so than any other ; but if 
patients, from supposing it to be so, take more care 
of themselves than they otherwise would, there is 
no harm in indulging their prejudice: on the tenth 
day, but not until then, you may allow your patient 
a little malt liquor. Porter, or fresh mild ale, re- 



DIET. 259 

lieves that sinking sensation at the stomach and ir- 
ritability of the nervous system, which are often so 
troublesome at this period ; you may, therefore, allow 
your patient to begin with half a pint a day of 
either, and, in a little time, it should be increased to 
half a pint three times a day, namely, at luncheon, 
dinner, and supper. Some women think it right to 
drink half a gallon of ale or porter a day, and will" 
call you a stingy doctor if you restrict them to the 
above-mentioned quantity. 

Women' generally have an abundance of milk : 
fluid nourishment seems more favourable to its secre- 
tion than that of a solid kind : if a patient goes to 
bed taking a solid supper only, little or no milk will 
be secreted ; but if she has taken a supper of two- 
thirds milk and one-third barley water, constituting 
what I call barley gruel, the milk will spout from 
the breasts during the night. If, therefore, the se- 
cretion of milk is slow and scanty, give them suffi- 
cient fluid nourishment. When is the patient to go 
out ? At the end of three weeks in the summer, and 
four in the winter, if all is going on well: you had 
better not allow it before, and not even then if the 
weather is colder than usual ; for if she suffers from 
it you will be blamed. You must bear in mind that 
whatever mischief happens after delivery, even if the 
woman should break her leg, it will be imputed to 
something that happened at her lying-in, and the 
doctor must bear the blame. 

It is sometimes an object in practice to diminish 
the quantity of milk, or rather to adopt a treatment 
by which it will be no longer secreted; this is occa- 
sionally, required of us on account of the ill-health 
of the mother, sometimes from the death of the child, 
or for less substantial reasons, such as the habits of 
fashionable life, which will not permit a mother to be 
nursing her child, as she should, every three hours. 
If the breasts are moderately hard only, easy, and 



260 MANAGEMENT OF WOMEN AFTER DELIVERY. 

but little distended with, milk, do not empty them, 
for secretion will be thereby encouraged, and they 
will soon fill again ; but if the breasts are very hard, 
painful, and much distended with milk, empty them 
partially, so as to relieve the distention, as often as 
this may be necessary. This may be done by an- 
other child, or by a woman. There are women in 
London who exercise no other profession — they ride 
about in hackney-coaches, look very fat, and seem 
to thrive on sucking their fellow-creatures : prescribe 
solid instead of fluid nourishment, and a black draught 
every second morning, until the secretion of milk 
has nearly or altogether ceased. During the first 
fortnight after delivery, the patient should be kept 
quiet, and as few visitors admitted as possible, as 
there is during this time a preternatural susceptibility 
of the nervous system. Thus much for the treat- 
ment of women after delivery under ordinary circum- 
stances. 



Section IV. — Unfavourable Nipples. 



The nipples in some women are preter naturally 
small and flat; this state of them is productive of 
much inconvenience, and does not always admit a 
remedy. Milk is secreted, the breasts become dis- 
tended and hard, and there is no nipple for the child 
to take hold of. You may sometimes succeed in elon- 
gating the nipple by the following method : — Take 
a pint decanter, or a wine bottle with a smooth mouth, 
fill it to the neck with boiling water, pour out this 



EXCORIATION OF THE NIPPLES. 261 

water almost immediately, and, provided it is not too 
hot, apply the mouth of the decanter to the flattened 
nipple. As the decanter cools a vacuum will be cre- 
ated, and the nipple will be elongated into its neck ; 
retain it thus a few minutes, when the bottle is to be 
gently removed by depressing it, and immediately 
apply the child. A vigorous child, of three or four 
weeks old, will sometimes draw out the nipple. Ma- 
chines have been invented for the purpose, but they 
are less to be depended on than the mouth of another 
child, of a woman, or the warm bottle. Foreigners 
very commonly employ for this purpose a puppy of 
about three or four days old ; this is a very good me- 
thod, but it is not to the taste of English females. 
When the nipples are flat, attempts should be made, 
a few weeks before the expected accouchement, to • 
draw them out. 



Section V. — Excoriation of the Nipples. 



It often happens that the nipples, from the friction 
of the child's tongue and gums, become excoriated ; 
they sometimes ulcerate, and deep chaps are formed 
nearly through them; every time the child sucks 
they bleed; the mother suffers exquisite pain, and 
her perseverance in nursing is a constant struggle 
between bodily pain and parental affection. The 
nurses and doctors have a long list of remedies for 
this complaint; but it is in general obstinate, and 
the remedies are ineffectual ; in attempting to cure 
it you are rowing against the stream ; as long as the 

34 



262 MANAGEMENT OF WOMEN AFTER DELIVERY. 

cause, viz., the action of the child's mouth in suck- 
ing, is renewed at short intervals, local applications 
are of little use. An aphthous state of the child's 
mouth sometimes induces and keeps up a consider- 
able irritation of the nipples. The following are the 
best known remedies for this affection : — Unguent, 
hydrarg. nit. dilut. ; solutions of the metallic salts, as 
two grains of the sulphate of zinc in an ounce of 
rose water ; a solution of the nitrate of silver, suffi- 
ciently strong to cause only a slight smarting, as a 
grain in an ounce of distilled water ; or half an ounce 
of brandy in half a pint of rose water. The nipples 
are to be washed with a little milk and water both 
before and after sucking ; and during the intervals 
these solutions are, by means of linen dipped into 
# them, to be applied constantly. There is a quack 
remedy in great repute among many females, it is 
called the nipple liniment; it is oily, and of a red- 
dish colour. A liniment, composed of three parts of 
basilicon and one of the compound tincture of ben- 
zoin, is recommended by some ; others keep the nip- 
ples constantly wet by linen dipped in cold water. 
Finely powdered gum-arabic sprinkled over the nip- 
ples both before and after nursing is sometimes bene- 
ficial. But as long as mechanical irritation is kept 
up by the action of sucking, remedies are but of little 
service. To prevent this irritation shields are in- 
vented, made of wood, ivory, silver, glass, &c. : those 
of glass are the best, as you can see whether the 
child draws milk or not : the shield is to be nearly 
covered with the common integument of the teat of 
a cow, which is stretched over it; it is to be applied 
over the nipple, which is thus protected, during the 
action of sucking. If properly used, this contrivance 
is in many cases successful ; but there is a right and 
a wrong method of employing it, and the nurse will 
most probably choose the latter. When the teat is 
sewn on the shield, its extremity should not extend 



EXCORIATION OF THE NIPPLES. 263 

far beyond the apex of the shield ; it may be left half 
or three-quarters of an inch beyond it; but if it pro- 
jects more, the child will get the teat between its 
gums and prevent the passage of the milk through 
it. The teat should also closely cover all the orifices 
to which it is stitched; for if air-holes are left, no 
vacuum will be formed, and the child will draw no- 
thing but air. If the excoriation and chaps are not 
remedied by any of these means, and the mother's 
health suffers from continued pains and irritation, 
you must recommend either a wet nurse or the wean- 
ing of the child. 

To prevent this tenderness of the nipples you put 
them under a system of training, for six weeks, or 
more, before delivery. The skin covering the nip- 
ples is thin and irritable, and therefore disposed to 
excoriation : this irritability is to be diminished, and 
the skin rendered thicker, by exposing the nipples 
to the air, and rubbing them for ten minutes three 
or four times a day, by washing them with an in- 
fusion of oak or pomegranate bark, or some vegeta- 
ble astringent. By a regular employment of these 
means, the skin covering the nipples will become 
thicker and harder, and its irritability will be di- 
minished. 



264 MANAGEMENT OF WOMEN AFTER DELIVERY. 



Section VI. — Mammary or Milk Abscess. 



The child should be applied to the breasts before 
they become hard and distended with milk; the 
child otherwise sucks with difficulty, the breasts are 
but partially relieved, they become painful, inflame 
and suppurate, causing distress to the patient, and an- 
noyance to the practitioner. The inflammation 
which ends in mammary abscess, is of the phleg- 
monous kind; and it may be produced by cold, as 
well as by distention of the lactiferous tubes ; pas- 
sions of the mind are also enumerated among its 
causes. Whether from negligence, from the claims 
of fashionable life, or more useful avocations, the 
nursing of the child is sometimes so long deferred, 
that the tubes become distended : this state of dis- 
tention is perhaps permitted to occur frequently ; at 
length, after the child has sucked, and the breasts 
are otherwise flaccid, there is felt in one part a small, 
hard, circumscribed tumour, which is painful on 
pressure ; in this tumour, phlegmonous inflamma- 
tion commences; there is chilliness succeeded by 
heat of skin, the tongue becomes white, the pulse 
quick, and the breast painful. The cure of this in- 
cipient disease by resolution must be immediately 
attempted ; for if allowed to go on three days, it will 
terminate in suppuration. The treatment, to some 
extent, resembles that of phlegmonous inflammation 
in any other part ; it consists in the application of 
leeches, in purging, and a low, cooling diet : in ad- 



MAMMARY Oil MILK ABSCESS. 265 

dition to which, it is of the highest importance to 
keep the lactiferous tubes empty. These minute 
vessels are, I think, spasmodically affected ; be this 
as it may, the breasts are most effectually disposed 
to permit the escape of the milk by hot fomentations, 
which are to be applied, for half an hour at a time, 
by means of flannels wrung out of hot water, and 
renewed every five minutes, while the escape of the 
steam is prevented by placing over them a wooden 
bowl of sufficient size, or some such contrivance. 
After the fomentation, immediately apply the child 
to the breast, or get it drawn by a woman, when it 
will be emptied readily, and the patient will be con- 
siderably relieved. The fomentations and drawing 
of the breasts should afterwards be so frequently re- 
peated, as to prevent an unpleasant degree of disten- 
tion ; in the intervals, cover the breast with a warm 
poultice, which I am informed diminishes the secre- 
tion of milk. Under a steady perseverance in this 
plan, the excitement of the constitution is quieted, 
the hard tumour gradually diminishes and disap- 
pears. Some practitioners recommend cold applica- 
tions, but they are extremely prejudicial, if only by 
rendering the abstraction of milk more difficult, to 
say nothing of the well-known fact that the disease 
is frequently produced by cold. Sometimes, in 
spite of the most judicious treatment, suppuration 
will take place; if the inflammation and other symp- 
toms obstinately continue for some days, if there are 
shiverings together with shooting pains in a particu- 
lar part of the breast, which is elevated, and has a 
shining appearance, suppuration has certainly com- 
menced. You will then relinquish the use of pur- 
gatives, and endeavour to hasten the suppurative 
process by hot fomentations every four hours, and 
by the application of thick, warm poultices ; in a few 
days more, the matter approaches the surface. Will 
you open the abscess ? If you do, you will relieve 



266 MANAGEMENT OF WOMEN AFTER DELIVERY. 

your patient from suffering, and • by the evacuation 
of the matter the constitutional disturbance ceases ; 
but the wound will not heal so soon, and the matu- 
ration of the abscess will not be so complete as if 
the whole process were left to nature. If there is 
great irritability of the nervous system, and agonis- 
ing pain attending the suppurative process, opium 
must be given in such doses as may be necessary. 
It sometimes happens that the wound does not heal 
favourably, the part continues hard, and sinuses are 
formed from whence pus is made to ooze by pres- 
sure ; the hardness is owing to the deposition of co- 
agulable lymph ; you must heal the sinuses, and the 
lymph will be gradually absorbed. Poultices must 
now be discontinued, and a weak solution of a me- 
tallic salt, as one or two grains of the sulphate of zinc 
in an ounce of rose water, is to be injected into the 
sinuses three or four times a day ; soft linen rags, 
saturated in a solution of double this strength, and 
covered with a fold of dry linen to prevent evapora- 
tion, are also to be applied externally. Some prac- 
titioners give internally the oxy muriate of mercury, 
in doses of a twelfth, an eighth, or a sixth of a 
grain, in decoction of sarsaparilla twice a day ; this 
is a good medicine. . They also apply a plaster over 
the part, composed of one-third of the extract of 
hemlock, and two-thirds of the emplastr. plumbi. 

Thus much for the general management of women 
after delivery, and for the treatment of those slighter 
affections, connected with the puerperal state, which 
do not endanger life, and which are of common oc- 
currence. I have now to speak of those diseases con- 
nected with parturition, which, though less frequent, 
are more severe or dangerous. 



ON PUERPERAL OR CHILD-BED FEVER. 267 



LECTURE THE SIXTH 



ON THE DISEASES OF WOMEN AFTER DELIVERY. 



Section I. — On Puerperal or Child-bed Fever. 



In general, patients do very well after delivery ; 
but now and then a frightful mortality occurs among 
lying-in women, the cause of which is the puerperal 
or child-bed fever. In the Hotel-Dieu at Paris, not 
long since, three-fourths of the women attacked with 
this formidable malady died. At Edinburgh, also, 
the mortality from this disease was very great. Some 
years ago, at the Westminster Lying-in Hospital, its 
ravages were such that they buried two in a coffin, in 
order to conceal from the public, as far as possible, 
the extent of the mortality. The prevalence of this 
fever at Sunderland gave rise to Dr. Armstrong's va- 
luable treatise on this subject. It prevailed at Leeds ; 
and Mr. Hey, junior, who also wrote on the subject, 
lost at that time about twelve patients. Even now, 
I and my colleague have to contend with puerperal 
fever at the Westminster Lying-in Hospital about 
every two years. The disease has been in many vil- 
lages no less fatal than in towns ; and one singularity 
of this disease is, that it often prevails in the practice 
of one medical man, while other practitioners of the 



268 DISEASES OF WOMEN AFTER DELIVERY. 

same district do not, perhaps, meet with a single case 
of it. The ravages of this fatal disease have also 
been confined to particular wards of a hospital, while 
the patients in other wards have entirely escaped it. 
There are two essential circumstances attendant 
on this disease, — fever and abdominal inflammation ; 
and it has long been a matter of dispute whether the 
fever produces the inflammation, or the inflammation 
the fever : of this I shall speak presently. The dis- 
ease sometimes commences and proceeds very insi- 
diously ; some of the most conspicuous symptoms, 
as vomiting, heat of skin, &c, being absent. In ge- 
neral it begins about the second, third, or fourth day 
after delivery. The common symptoms are, rigors, 
succeeded by heat of skin ; a full, hard, rapid pulse; 
occasional vomitings ; distress of countenance ; great 
debility, and a suppression of the secretion of milk : 
there is permanent pain and tenderness in some part 
of the abdomen, most frequently about the umbilicus, 
which is so much increased by pressure, that even 
the approach of your hand makes the woman shrink. 
Some patients tell you, when questioned, (as in pleu- 
risy and peritonitis,) that the rigors and constitu- 
tional disturbance preceded the pain ; and others will 
say, that the pain preceded the constitutional affec- 
tion. The disease consists of peritoneal inflamma- 
tion, with continued fever. The acute stage conti- 
nues from one to two or three days ; during this time 
the rigors are severe ; the skin very hot, though at 
some periods clammy ; the pulse quick and full ; the 
belly tumid, and susceptible of great pain from the 
slightest pressure ; the tongue is white ; the respira- 
tion short and quick, and the countenance anxious : 
these are the signs of abdominal inflammation, and 
this stage of the disease is often a fatal one. After 
these symptoms have continued about forty-eight 
hours, or at most three days, the pain is somewhat 
diminished ; but the belly is more tumid, the pulse 






ON PUERPERAL OR CHILD-BED FEVER. 269 

becomes smaller and more rapid, beating from 130 
or 140 to 150 in a minute ; the lips are pallid, the 
countenance sunk, the breathing is still quick, and 
the woman lies constantly on her back. In about 
five or six days from the commencement of the dis- 
ease the third stage begins; the countenance is then 
still more sunk and pallid, the breathing more hur- 
ried, the pulse quicker and more feeble ; the pain in 
the abdomen is less, but its parietes are distended 
like a drum ; the woman moves restlessly about the 
bed ; her mind becomes affected ; there is delirium, 
which, however, is not constant, and presently she 
dies. The progress of this disease is sometimes so 
rapid as to be fatal in less than forty-eight hours. 
On examination after death, the vessels of the omen- 
tum and peritoneum are found to be turgid with 
blood ; there are extensive adhesions in many parts 
of the abdomen, which is partly distended by air, 
and partly by effused serum, with flakes of lymph 
floating in it; sometimes there is on the intestines a 
concretion of a fatty appearance ; the uterus, in par- 
ticular, which is sometimes covered by a coat of coa- 
gulable lymph, and the viscera generally, are found 
to have suffered violent inflammation. The essential 
and obvious fact is, that there has been acute perito- 
neal inflammation ; that all the viscera have suffered 
inflammation, and none in a greater degree than the 
uterus. 

■ The pain in the abdomen, in puerperal fever, 
though it may vary in its degree, is constant ; it is 
increased by pressure, and accompanied by fever : 
these circumstances will distinguish it from after- 
pains, between which there is an interval, and during 
which there is neither fever nor tenderness of the 
abdomen on slight pressure. 

The cause of puerperal fever is unknown ; it is, 
however, generally believed to arise from some spe- 
cific contagion : for my own part, I believe it some- 

35 



270 DISEASES OF WOMEN AFTER DELIVERY. 

times occurs, without an origin of this kind, as by 
common peritoneal inflammation, of which fever is 
the consequence ; but there certainly is a disease of 
this kind which is infectious, and then it plays the 
very devil; here the fever precedes the inflammation. 
Thus it is sometimes a sporadic disease, not being 
infectious and at other times the result of contagion ; 
but in my own practice I have never seen the latter 
exemplified. Before I was as cautious as I am now 
I did not change my clothes before visiting my other 
midwifery patients, after seeing one who was suffer- 
ing under puerperal fever, yet I never in one in- 
stance carried the infection from one patient to an- 
other. Nevertheless, the disease is affirmed to be 
infectious, and well authenticated circumstances 
seem to favour this opinion. I. have heard it said^by 
medical men, that they have carried the infection 
from one patient to another, and this after a journey 
of six miles, which has been performed against a 
rough wind. One practitioner informed me he was 
at the opening of the body of a female who died of 
this malady : he carried the infection to an institu- 
tion, and almost all the patients died who were at- 
tacked by it. Sometimes it occurs only in one hos- 
pital of a city, at other times it prevails only in 
private practice. Although my own practice has 
never furnished me with proofs of the infectious 
character of the disease, I think it right to act 
with caution; and now make it a rule never to 
visit my other patients after seeing one suffering 
from puerperal fever, without first changing my 
clothes : this rule obliges me to keep a suit of clothes 
expressly for the purpose of visiting my contaminated 
patients. Fools never learn but in the dear school 
of experience ; I do not feel disposed, in the present 
instance, to take a lesson in this school. 

The miasma of puerperal fever rarely infects 
women who are not yet delivered ; but it sometimes 



ON PUERPERAL OR CHILD-BED FEVER. 271 

does, and it then occasions abortion, to which death 
succeeds in two or three days. The late Sir R. 
Croft lent me some papers on this subject, in which 
there were related twelve cases of this kind ; among 
these cases, it was stated that a pregnant woman was 
attending on a friend in puerperal fever, who died ; 
she was herself attacked with the common symp- 
toms of this disease ; it produced abortion, and she 
died : and the usual appearances were found on 
examination after death. , The washerwoman who 
washed her linen was pregnant: she also had symp- 
toms resembling those of puerperal fever ; but being 
freely bled, purged, &c, she recovered. The disease 
has been carried by a nurse to a pregnant woman. 
Corrupt air, whether that of small, close apartments 
badly ventilated, or of marshy situations, stinking 
ditches, &c, seem to favour the production of this 
disease. The London Lying-in Hospital has very 
few cases of this description ; in the Westminster 
Hospital they are very numerous. 

There exists at present a great difference of opinion 
with respect to treatment of this disease : nearly all 
who have written or lectured on the subject up to the 
present time have considered it a typhoid disease, 
characterized by great debility and inflammation of 
a low character; they were consequently deterred 
from measures of active depletion. Dr. Clark gave 
bark, with compound spirit of ammonia. Dr. Wil- 
liam Hunter said it was the only disease connected 
with the puerperal state in which he could do no 
good; "for," says he, "I have tried both the stimu- 
lating and the depleting plan without success." Dr. 
A. Gordon, of Aberdeen, considers the disease as an 
inflammation of a severe kind ; he employed an ac- 
tive treatment agreeably with this view, which he 
found to a considerable extent successful. M. Doul- 
cet, of Paris, advised emetics of ipecacuanha to be 
daily repeated until the severity of the symptoms 



272 DISEASES OF WOMEN AFTER DELIVERY. 

was subdued : this disease had proved very fatal at 
the Hotel-Dieu : but on adopting this treatment, al- 
most every case did well; but the success of the 
remedy depends on it being given at the very com- 
mencement of the attack. It is a severe inflamma- 
tory disease, and will bear depletion, which must be 
employed early and boldly, whether in its sporadic or 
infectious form. 

The reason why this treatment was not found more 
successful formerly was that it was not resorted to 
till too late, or it was employed with timidity : some- 
times, also, other diseases were mistaken for puerperal 
fever. Dr. Butter, of Derby, who has written on 
puerperal fever, has evidently confounded other dis- 
eases with it : in his account of it he says, that it 
goes on for four or five weeks, and the pain in the 
abdomen is not constant. These two remarks con- 
vince me that he has not correctly distinguished the 
disease ; for in puerperal fever the pain in the abdo- 
men is constant ; and if the disease is not subdued 
in a week, it will kill the patient. The disease which 
Dr. Butter describes, is a slow remittent fever, unat- 
tended with peritoneal inflammation, but connected 
with visceral disorder : this I have seen, and here 
bleeding would, I think, generally be prejudicial. 
Dr. Armstrong and Mr. Hey, jun., whose books on 
this subject are worth reading, at first attempted to 
cure puerperal fever by the stimulating plan, consi- 
dering it a low disease : they found this treatment 
unsuccessful, and abandoned it for the depleting sys- 
tem, the results of which were much more favour- 
able. Inquire among practitioners old enough to 
have had experience, yet young enough to be unbi- 
assed by the notions of our forefathers, and they will 
tell you that it is decidedly an inflammatory disease, 
the acute stage of which is of short duration. I 
therefore say, that the disease must be treated by bold 
and early depletion; and the more I see of it, the 



ON PUERPERAL OR CHILD-BED FEVER. 273 

more I am convinced of the propriety of the maxim, 
" hit hard, bnt hit early." Lose no time in the vigo- 
rous employment of depleting measures, for the acute 
stage will often pass away in twenty -four hours, nay, 
if violent at its commencement, in twelve hours, 
when the patient is beyond the reach of art : gene- 
rally speaking, in twenty-four hours the time for 
active depletion is over. As soon as the rigors have 
ceased, and the hot stage has commenced, if the pa- 
tient is robust, immediately take away from twenty 
to thirty ounces of blood from the arm; it is import- 
ant that this should flow in a full stream, let the ori- 
fice therefore be large, and not like the prick of a 
pin. It is desirable that the bleeding should produce 
a syncope; if, therefore, the patient does not faint 
when sixteen ounces have been abstracted, set her 
upright in bed, and if she then faints, do not attempt 
to rouse her, but allow the syncope to continue : on 
her recovery, you will probably find that the pain 
and all the previous symptoms have ceased. Leeches, 
succeeded by hot fomentations or poultices over the 
abdomen, and often repeated, will now be of consi- 
derable benefit, by unloading the minute vessels of 
the part. 

The next important object is to excite free and 
copious purging, which will be effectually done by 
giving ten grains of calomel, followed every two or 
three hours by two or three drachms of the sulphate 
of magnesia and a few grains of jalap, either in 
water or in two ounces of infusion of senna. Dr. 
Armstrong begins with half a drachm of calomel. 
If in six or eight hours the symptoms should in- 
crease, you must bleed again to the amount of sixteen 
or twenty ounces, or in proportion to the severity of 
the disease. The patient must be seen a few hours 
after the first bleeding ; for although after syncope 
the pain and other symptoms appear to cease, yet on 
the renewal of the circulation they may return with 



274 DISEASES OF WOMEN AFTER DELIVERY. 

perhaps their previous severity. By the early em- 
ployment of these vigorous measures the disease will 
in general be subdued in a few hours, and the fate 
of your patient is determined. After another inter- 
val of six or eight hours depletion by general bleed- 
ing is seldom proper ; but if a third bleeding is in- 
dicated by the state of the pulse, tenderness, &c, of 
the abdomen, let it be a cautious one ; you may with 
benefit in place of it put on a regiment of leeches 
over the abdomen, two or three dozen, allow them to 
draw as long as they will, and foment the bowels 
frequently after they come off, or cover the abdomen 
with a bag of scalded bran, which is light, and re- 
tains the heat ; this is to be renewed as often as may 
be necessary : give the liquor ammonias acetatis in 
large doses, with sulphate of magnesia, jalap, senna, 
or castor oil, every three or four hours, so as to pro- 
cure daily five or six evacuations from the bowels, 
till the disease is arrested ; and let the diet from the 
commencement consist of gruel, barley water, and 
tea. See your patient eight hours after the second 
bleeding, and if she is not saved by this time, her 
destiny is in general settled ; she will not be saved 
at all. Something, however, I think, might be done 
for our patient after we have fired our heavy shot. 
The continental practitioners recommend calomel 
and opium every six hours after bleeding. Calomel, 
as an anti-inflammatory remedy, has a powerful in- 
fluence over many acute diseases ; it has a specific 
influence in acute iritis, in croup, inflammation of 
the liver, &c. ; and it is said to have as specific an 
effect in puerperal peritonitis. It should be given in 
five grain doses every four hours, until it produces 
its specific action on the system. Should violent 
purging or griping come on during the employment 
of calomel, small doses of opium may be combined 
with it, or given at intermediate periods. When the 
system becomes under the peculiar influence of mer- 



ON PUERPERAL OR CHILD-BED FEVER. 275 

cury, the symptoms speedily subside, and the re- 
covery of your patient is rendered much more pro- 
bable; the remedy is now to be withdrawn, or 
repeated in smaller doses, and at longer intervals : 
mild aperients are now to be regularly employed. 

Peritoneal inflammation often follows puerperal 
convulsions. Many of the sporadic cases originate 
from irritation, produced by the contents of the 
bowels ; when the symptoms will be rigors, followed 
by heat of skin, quick pulse, and tenderness of the 
abdomen. The patient enters the lying-in chamber 
with bowels which have for some time been but 
partially evacuated; and though these symptoms 
when they occur may be relieved by bleeding and 
aperients, yet the recovery of the patient is incom- 
plete, till, perhaps after a large dose of castor oil, 
there is discharged a load of indurated fseces, which 
have been for a long time accumulating, and will 
not be removed by saline aperients. Active purging 
is in all cases as essential as bleeding. If the symp- 
toms of this disease are connected with a loaded 
state of the bowels, the chief point is to empty them ; 
but although this moderate form of the disease may 
yield immediately to purging and warm fomenta- 
tions, yet if it threatens any considerable degree of 
violence or danger, it is best at once to adopt those 
vigorous measures just recommended, which will 
alone be sufficient to resist it. 



276 DISEASES OF WOMEN AFTER DELIVERY. 



Section II. — On Inflammation of the Uterus, 



Inflammation of the uterus may be excited by 
local injuries, by cold, and other causes ; and there 
seems rather a particular disposition to do it after 
uterine haemorrhage. In this disease the pain in the 
abdomen is less diffused than in peritoneal inflamma- 
tion, being confined chiefly to the lower part of the 
belly; the uterus forms a large, hard, circumscribed 
tumour, which is extremely painful on pressure, 
reaching almost to the umbilicus. Some of the symp- 
toms of this disease, as rigors, succeeded by a hot 
skin, rapid pulse, and sometimes vomiting, are com- 
mon also to puerperal peritonitis ; but inflammation 
of the uterus may be distinguished by the situation 
of the pain, which is confined to the hypogastric 
region, and also by the cessation of the lochia. In- 
flammation of the uterus is often accompanied by 
considerable irritation of the bladder, with strangury ; 
if it is not attacked early, and with vigour, gangrene 
of the inner surface of the uterus is likely to take 
place, and the patient will die about the fifth day. 
The uterus is found on examination after death to 
be very large ; its parietes are much thickened, and 
its irmer surface exhibits a gangrenous appearance. 
Inflammation of the uterus may exist in different de- 
grees, and it is often combined with peritonitis ; but 
when a simple disease, in general it yields readily to 
active remedies. The treatment is the same as that 
just recommended in puerperal peritonitis; the safety 



ON PUERPERAL MANIA. 277 

of the patient will depend on early and bold deple- 
tion. In both affections the rule is the same : bleed- 
freely in the -commencement, and keep up an ade- 
quate purging ; and you will not, upon an average, 
lose more than one patient in seven. 



Section III. — On Puerperal Mania. 



Nervous irritation is very common after delivery, 
more especially among fashionable ladies, and this 
may exist in any degree between mere peevishness 
and downright madness. Some women, though 
naturally amiable and good tempered, are so irritable 
after delivery that their husbands cannot enter their 
bed-rooms without getting a curtain lecture ; others 
are thoroughly mad. I lately attended a lady who 
was fond of music, poetry, and painting ; even during 
labour she amused herself by reciting poetry. A 
few days after delivery, she had an irritated pulse of 
a hundred and twenty in a minute ; she said she felt 
quite well, and was not aware of any derangement 
of her health. This nervous excitement continued 
for several days, she then became delirious, she could 
not sleep, and her pulse got up to a hundred and 
thirty. I expected she would have had puerperal 
mania, but happily this irritability of the system 
subsided, and she was soon well. When puerperal 
mania does take place, the patient swears, bellows, 
recites poetry, talks bawdy, and kicks up such a row 
that there is the devil to pay in the house ; it is odd 
that women who have been delicately brought up, 

36 



278 DISEASES OF WOMEN AFTER DELIVERY. 

and chastely educated, should have such rubbish in 
their minds. This disease seldom impairs either the 
mind or the body ; generally speaking, you may put 
it down in your memory, that these cases end well 
in a few weeks, but sometimes not till the expiration 
of a few months. It is possible, however, that puer- 
peral mania may terminate fatally, or it may be in- 
jurious both to the body and mind. The fatal cases 
seem to be those in which there is considerable dis- 
turbance of the circulation, together with inflamma- 
tion of the membranes of the brain : I have seen 
three cases of this/kind ; but those dependent merely 
upon nervous irritation do well. I once attended a 
patient with an eminent accoucheur, who thought 
this disease was never fatal, and in his prognosis, told 
her friends she would recover ; the patient, however, 
died. 

A patient suffering under puerperal mania must 
be kept extremely quiet, and every precaution must 
be taken to prevent her doing injury to herself, to 
the infant or her friends. There is a great propen- 
sity to suicide ; the windows, therefore, must be se- 
cured, and everything must be removed, down even 
to her garters, with which such a purpose may be 
effected ; if anything of this kind is placed within 
her reach, she will probably secrete it, and wait for 
an opportunity of employing it. If necessary, a 
straight waistcoat must be put on ; let a careful and 
experienced nurse attend her ; the disease must, in 
great measure, be allowed to run its course, and this 
is what happens with those who profess to cure it. 
The best attendant is a nurse who has been accus- 
tomed to similar cases, who is familiar with their 
mischievous propensities and can anticipate their 
plottings. In this disease the alimentary canal is 
apt to become loaded, and the nervous system is irri- 
tated in consequence : it is therefore necessary to 
administer purgatives so frequently as to prevent any 



ON PUERPERAL MANIA. 279 

accumulation in the bowels. As to bleeding, it is 
not necessary, unless there are obvious symptoms of 
congestion of the brain. I believe the best and most 
successful treatment in these cases consists in taking 
care of the digestive organs : the bowels should be 
kept regularly evacuated, and the secretions should 
be brought to a healthy state, by exhibiting mild pre- 
parations of mercury : in addition to this, keep the 
patient as tranquil as circumstances will admit. Can 
you prevent puerperal mania ? A lady, a few days 
after labour, became maniacal. The symptoms sub- 
sided in about five weeks, and she got well. She 
again became pregnant, and I attended her, but was 
ignorant of her former malady, until the nurse in- 
formed me of it in the progress of the labour : and 
if hereditary predisposition has anything to do with 
this disease, this must have been an emphatic in- 
stance ; for nearly all her relatives were mad : or 
had died mad ; and to keep up the breed, this lady 
had married a gentleman whose family were equally 
mad. After her first labour, her friends thinking it a 
time for merriment and rejoicing, were footing it 
about the house, which resembled a rabbit warren. I 
determined it should this time be otherwise, and suc- 
ceeded in keeping the house quiet. She was de- 
livered easily and did well for the first ten days ; 
when, as the devil would have it, a fire broke out 
near the house in which st^e lived. The attendants 
very properly kept her ignorant of the circumstances ; 
but in the evening she saw some sparks flying about : 
almost immediately after this I happened to call, 
thinking the family would be in a state of alarm ; 
she looked and talked rather oddily, and the paroxysm 
was evidently coming on. I slept in the house that 
night, and at two o'clock was called up. On enter- 
ing her bed-room she said, " Who's there ?" I merely 
answered, " Dr. Gooch." She replied, " Sit down- 
now look at my forehead, do you see anything ?"«— 



280 DISEASES OF WOMEN AFTER DELIVERY. 

"No, ma'am." " Look again." — "I see nothing 
there ;" — then clasping her hands, with a whining, 
methodistical tone, she exclaimed, " Then I was pre- 
sumptuous ; I am deceived, I thought a glorious 
light issued from my temples, and that I was the 
Virgin Mary." I took away a few ounces of blood, 
by cupping on the head, over the sutures, but with 
little benefit. Her bowels were attended to, and at 
the end of three weeks she was quite well, without 
seeming to have been cured by anything that was 
done. This lady again became pregnant, and about 
three weeks before delivery I called to see her : there 
was evident derangement of the hepatic function ; 
she had white stools, yellow eyes, and a jaundiced 
face, and passed yellow urine. I gave her one grain of 
calomel every night, with five grains of the pil. aloes 
cum myrrha, wdiich produced two or three evacua- 
tions daily ; this plan was continued also after de- 
livery, and she had no maniacal affection. When, 
therefore, it is known, that there is a disposition to 
this complaint, endeavour to prevent it, by adminis- 
tering, both before and after delivery, some purgative, 
combined with an alterative dose of mercury, by 
which a regular action will be kept up on the 
bowels. 

A lady, who had for some time been maniacal, 
was confined by a straight waistcoat, and had been 
accustomed to evacuate her bowels in the bed ; an 
active purgative was given to her ; soon after taking 
it she said, " Nurse, let me go to the water-closet;" 
and the nurse, astonished at this rational request, 
unloosed the straight waistcoat, and led her to the 
water-closet adjoining, where the bowels were 
relieved of a prodigious load of feculent matter : she 
very soon after recovered perfectly. Such medi- 
cines as effectually clear the alimentary canal are 
the most beneficial in these cases. The disease is of 
a chronic kind, but it is rarely fatal ; patients have, 



ON PUERPERAL MANIA. 281 

while it continues, the most strange ideas imagina- 
ble ; you must not, on any account, combat these 
fancies by argument, for they will defend their 
absurdities stoutly, and your attempt to correct, will 
serve only to confirm them. You must draw their 
minds from their morbid fancies by engaging them 
on some other subject. I would rather allow a 
patient to think her legs were made of straw, and 
her body of glass, than dispute either proposition. 
A lady who suffered for some time under puerperal 
mania, was at length removed from, her friends, and 
placed in a mad-house near London ; she attempted 
several times to destroy herself, and it was necessary 
to keep on a straight waistcoat. She once drank 
about an ounce of dilute muriatic acid ; but as she had 
just before taken a pint of fluid, though her throat 
suffered, her stomach was not injured by it ; half a 
drachm of sulphate of zinc was immediately given, 
which fully evacuated the stomach, and the acid did 
no material harm. She also tried to swallow sponge, 
and to prick her arteries and veins with pins; at 
length she became impressed with notions of the 
most gloomy description ; of her having committed 
crimes which had brought ruin and disgrace on her- 
self and family, and which had occasioned the death 
of her husband and children. Thus she went on for 
some weeks without any favourable change, when 
the husband wished to see her ; the doctor who con- 
ducted the establishment did not approve of it ; but 
the husband said his wife believed him dead, and he 
wished to ascertain if his presence would correct this 
notion. The doctor said it would only confirm it, 
and that his wife would say he was a spirit : how- 
ever, the husband was permitted to see her, and was 
accordingly announced by the nurse : she was vio- 
lently enraged, and said to the nurse, " You insult 
me — he is dead." On the husband walking into the 
room, she uttered a loud shriek, ran to a corner, hid 



282 DISEASES OF WOMEN AFTER DELIVERY. 

her face, and said, " You are a supernatural being." 
On looking up, a gleam of hope and despair seemed 
alternately to engage her mind ; he tried to convince 
her of his being a corporeal reality, but to no pur- 
pose; which confirmed the doctor's prediction. He 
then endeavoured to withdraw her mind from the 
idea of his death ; he took her arm and walked about, 
and changing the subject, familiarly said, " How do 
you think I have been living since I saw you?" she 
instantly replied, "Tell me;" he led the conversa- 
tion to the manner in which they had both formerly 
lived, talked of their children, &c; she appeared 
interested; and when he thought he had gained 
possession of her mind, he suddenly asked her, if 
she now thought him a ghost ; and she burst into 
laughter. He thus convinced her that he was not 
dead, and restored her to a state of perfect sanity :— - 
he dined, drank tea, and supped with her, and she 
was perfectly rational ; he went the next day to see 
her, and found her quite sane. Her attendants were 
astonished at the sudden change. Do not argue with 
them, but with dexterity of address divert their 
minds from maniacal ideas, which, together with 
sea-bathino-, and constant attention to the bowels, 
will prove" 'the most successful method of treating 

thi^i disease. 

Puerperal mania sometimes occurs after puerperal 
convulsions; it is then generally fatal. 



THE SWELLED LEG OF LYING-IN WOMEN. 283 



Section IV. — Phlegmasia Alba Dolens Pacrperarum; 
or the Swelled Leg of Lying-in Women. 



This is a singular and obstinate complaint, and is 
one of the latest to which lying-in women are liable ; 
it seldom occurs in less than a week after delivery, 
and sometimes not in less than a month. The 
attack is not preceded by loss of appetite, or of 
sleep ; immediately preceding it your patient may 
look well, but her pulse will be found very quick; 
from which circumstance you may apprehend either 
phlegmasia dolens, milk abscess, or mischief of some 
kind. But with or without precursory symptoms, 
the swelling of the limb is attended with pain and 
fever. The pain is generally confined to one part, 
as to the groin, the thigh, or the upper part of the 
calf of the leg, and it is accompanied by rigors, heat 
of skin, and a rapid pulse ; these symptoms continue 
from twelve to twenty-four hours, constituting the 
first stage of the disease. The second stage then 
begins ; the limb swells from the painful part 
upwards and downwards ; from the toes to the groin 
it is hard, but does not pit, as it is termed, on pres- 
sure ; it has a shining appearance ; presents to the 
touch the sensation of many slight irregularities ; it 
is painful on pressure ; and has every character of 
inflammation, except that it is white, instead of red. 
There is now loss of appetite, with general constitu- 
tional derangement; these symptoms continue for 
eight or ten day?, which is about the duration of the 
acute stage of the disease. The pain, heat of skin, 



234 DISEASES OF WOMEN AFTER DELIVERY. 

and quickness of the pulse, now subside; there 
ensues much constitutional debility; the limb is 
less tender to the touch, but is still greatly swollen ; 
this may be called the third stage of the disease, 
which continues a long time. Very slowly the 
limb regains its accustomed size and strength ; the 
patient limps for a considerable period, during which 
she gradually recovers her health. This complaint 
is in general confined to one extremity, though it 
sometimes affects both in succession; the labium 
only of the affected side participates in the swelling, 
while the other remains in its natural state.* The 
disease rarely terminates in suppuration. 

Phlegmasia dolens has been supposed to proceed 
from inflammation of the absorbent glands in the 
groin which are generally found to be enlarged, by 
which the passage of lymph is obstructed; the 
lymphatics become in consequence distended, burst, 
and their contents are effused into the cellular sub- 
stance of the limb. This disease occurs after easy, 
as well as after difficult labour ; and as it is not fata], 
no anatomical facts relative to it have been ascer- 
tained. If called upon for a prognosis, you may 
promise a favourable result; though you must give 
your patient and her friends to understand that it is 
a complaint usually of very long continuance. 

In the treatment of this disease there are three 
principal indications : to subdue it in the first stage; 
if this cannot be done, to shorten the duration of the 
second stage ; and to promote the absorption of the 
effused lymph in the third stage. If the patient is 

* This circumstance is considered by Mr. White, of Man- 
chester, as the pathognomonic symptom of the disease ; in his work 
on this subject he says, " I must beg leave to impress this upon 
my readers, that when one limb only is affected, the swelling is 
confined so exactly to the labium pudendi of that side, that if a 
line were drawn from the navel to the anus, it would be found 
never to go beyond that line in the smallest degree." Part ii. 
p. 7. 






THE SWELLED LEG OF LYING-IN WOMEN. 285 

seen in the first stage before the tumefaction begins, 
you may sometimes succeed in arresting the pro- 
gress of the disease, by the application of ten or a 
dozen leeches to the painful part, and by giving a 
brisk purge of calomel, jalap, and senna. Let the 
leeches remain on until they fall off, and then pro- 
mote the bleeding by fomentations with hot vinegar 
for several hours. But you may ask, "How is it to 
be known that the patient would have had this com- 
plaint, if these remedies had not been employed?" 
All medical evidence leads only to supposition : if 
you look for mathematical proofs you will be disap- 
pointed. Should this treatment not succeed, or if 
the second stage has commenced before you see the 
patient, you must, notwithstanding, apply leeches to 
the most painful part, and give sudorific medicines, 
as the liquor ammonise acetatis, tartarized antimony, 
together with purgatives : the diet must consist of 
gruel, &c, with abstinence from all animal food and 
fermented liquors. It is recommended by some, 
after a copious bleeding by leeches, to give one 
grain of calomel with two or three of antimony, and 
half a grain of opium every five or six hours, and to 
apply several blisters in succession to the part 
affected. After about ten days the inflammatory 
symptoms have generally subsided ; yet the limb is 
still perhaps double its natural size. The treatment 
now indicated, consists in the employment of those 
means which are at once calculated to restore the 
patient's strength, and to promote the absorption of 
that which has been effused into the cellular mem- 
brane of the limb. The former object will be pro- 
moted by country air, gentle exercise, nutritious 
diet, acid, and bitter tonics ; and the latter by friction 
with stimulating liniments, aided by the pressure of 
a regularly and well applied flannel roller. Strap- 
ping the limb from the toes to the groin with adhe- 
sive plaster has an excellent effect ; I have seen the 

37 



286 DISEASES OF WOMEN AFTER DELIVERY. 

size of the limb diminish rapidly under this kind of 
bandage. I have known an instance of the occur- 
rence of this disease after abortion. There is reason, 
I think, to believe that an unhealthy and irritated 
state of the uterus, attended with fetid discharge, 
may give rise to this complaint ; take care, therefore, 
to have the vagina w^ell cleansed of the lochial, or 
other fetid discharges, by the use of a syringe and 
warm water. I have seen this disease ensue from 
the application of a ligature to a polypus uteri, which 
has been followed by a highly fetid discharge. 

I have sometimes met with a disease very much 
resembling phlegmasia dolens : with the exception, 
however, that the limb does not swell ; there is con- 
siderable pain shooting from the groin down the 
thigh, which is attended with fever. The constitu- 
tional treatment of this affection will consist in the 
exhibition of purgatives, sudorifics, &c. ; and I have 
found a circular blister round the thigh, just above 
the knee, like a garter, productive of great benefit. 



Section V. — Inversion of the Uterus. 



I formerly stated certain rules for the manage- 
ment of the placenta, and observed that any devia- 
tion from these rules might occasion haemorrhage or 
inversion of the uterus : of the former I have already 
spoken, and have now to call your attention to the 
latter. After the expulsion of the child, the uterus, 
not immediately contracting to expel the after-birth, 
remains large and flaccid : in this state it is surpris- 



INVERSION OF THE UTERUS. 287 

ing how slight a degree of force applied to the cord 
will invert the uterus, or turn it inside out. A prac- 
titioner informed me, that in one instance he inverted 
the uterus by merely putting the cord on the stretch. 
Dr. William Hunter used to say, when the uterus 
was in the state just described, it was as easily 
inverted as the finger of a glove ; but when it was 
contracted, it was as difficult to invert as a jack-boot 
Inversion of the uterus may take place in different 
degrees, in proportion to which the symptoms of its 
occurrence will be manifest. If, after the removal 
of the placenta, haemorrhage takes place, with violent 
and rapid pains, which may seem to be after-pains, 
attended by a sense of bearing-down, and of bulk and 
fulness in the vagina, you may suspect inversion of 
the uterus to have taken place. The pain and irri- 
tation which this complaint occasions, sometimes, in- 
dependently of haemorrhage, induce frequent syncope, 
convulsions, and death. Should your patient suffer 
from the symptoms just mentioned, an examination 
must immediately be resorted to ; and in proportion to 
the degree of inversion, so will it be more or less 
readily ascertained. The fundus of the uterus may 
be merely depressed, forming a large dimple like the 
bottom of a wine bottle. In this case, making a 
common examination per vaginam will not do ; but 
you must pass your hand into the vagina, and your 
fingers into the cavity of the uterus, when you will 
feel the convex portion of the inverted uterus : by an 
examination externally, also, the uterus will not pre- 
sent its usual defined roundness ; but a considerable 
depression, will be felt at its fundus. This slight de- 
gree of inversion is the most difficult of detection. 
When the inverted portion has descended on, or pro- 
truded through, the os uteri, it is easily felt. It some- 
times descends so low that there is a tumour pro- 
jecting through the os tincse into the vagina, large 
and round, somewhat resembling the head of a child, 



288 DISEASES OF WOMEN AFTER DELIVERY. 

for which, and also for a polypus, it has been mis- 
taken. The tumour, however, will be distinguished 
from the head of a child by its being 1 very sensitive 
and much softer ; and from a polypus, by its being 
sensitive. The inversion is sometimes such, that the 
uterus protrudes through the external orifice, and 
hangs like a calibash from between the labia. This 
displacement is often produced by improper force ap- 
plied to the umbilical cord ; the expulsion of the pla- 
centa is tardy ; the accoucheur passes his finger 
through the vagina and os uteri, and does not feel the 
placenta, — it is high up and attached, — he waits ; 
but getting impatient, puts the cord on the stretch, 
using, perhaps, but trifling extractive force, and 
down comes the placenta into the vagina: he ex- 
amines, and finds it adhering to something : this is 
the uterus turned inside out ; and, in this case, the 
accident will be ascertained before it is denoted by 
symptoms. If the uterus be inverted, and the whole 
surface of the placenta still adherent to it, there will 
be no haemorrhage, but if the placenta is partially ad- 
herent only, haemorrhage will take place. The uterus 
can never be inverted without great danger to the 
life of the patient. If haemorrhage does not kill her, 
the inverted portion will become strangulated by the 
os tincaB, which acts on it like a ligature, and in- 
flammation will follow, terminating, probably, in 
gangrene and death. B ut suppose the patient escapes 
these evils, and the uterus remains still inverted, — 
the art of man cannot restore it to its natural situation ; 
she is liable to frightfully profuse menorrhagia, in- 
curable leucorrhoea, and severe constitutional affec- 
tions, which hasten her to the grave. Some women 
(rare exceptions) have not suffered materially in their 
health from a chronic inversion of the uterus; but, 
however fortunate a woman may be in other respects, 
her vagina will be plugged up. Most cases of in- 
verted uterus are produced by improper pulling at 



INVERSION OF THE UTERUS. 289 

the cord. It is said that it may also occur sponta- 
neously : the child may be expelled quickly, and the 
cord may be shortened by being twisted round its 
neck ; or it may naturally be very short ; thus, the 
placenta is pulled down, and the fundus uteri follows 
with it ; but, generally speaking, this serious com- 
plaint is occasioned by mismanagement on the part 
of the midwife. The dangers resulting from inver- 
sion of the uterus are these : first, profuse and dan- 
gerous hsemorrhage ; secondly, inflammation of the 
inverted portion, terminating in gangrene ; these 
dangers follow quickly on delivery ; but, if the patient 
escape them, she is still liable to profuse menorrhagia, 
and leucorrhcea ; and whether she does or does not 
suffer from these discharges, she is for life the subject 
of a disease which renders her unfit for the duties ot 
the marriage state. 

The first object of treatment is to reduce the inver- 
sion, and there is only one moment in which this 
can be done with certainty, namely, immediately 
after the inversion has taken place, when it will be 
a matter of great facility. But if a few days elapse, 
Dr. Denman says you will be foiled in your efforts 
to return the uterus to its natural situation ; he has 
often attempted this after such an interval, but never 
succeeded ; he has sometimes found it impracticable 
even a few hours after the displacement has occurred ; 
hence we perceive the great importance of its being 
detected early. If the uterus has descended into the 
vagina, or protrudes externally, the inversion is 
ascertained easily, but is reduced with difficulty; if 
the inversion is in a more trifling degree, resembling, 
as I have before said, the dimple at the bottom of a 
wine bottle, it is detected with difficulty, but reduced 
with ease. In this latter case, to return the inverted 
portion, the patient is placed across the bed, the 
hand of the accoucheur must be introduced into the 
vagina, and the os uteri gradually and carefully 



290 DISEASES OF WOMEN AFTER DELIVERY. 

dilated, so as to admit the passage of the hand into 
its cavity ; the uterus is to be steadied by the other 
hand applied externally, and the dimple, or inverted 
portion, may be thus readily replaced. By friction 
and pressure on the abdomen you now excite the 
uterus to contract, but remember, you must not with- 
draw your hand until it is almost expelled by the con- 
traction of the uterus. If a complete inversion of the 
uterus has taken place, the reduction is not so easy ; 
and should the placenta be still adherent, it becomes 
a question whether to separate it, and return the 
inverted uterus, or return the uterus with the pla- 
centa attached to it. If you attempt the reduction 
with the placenta adherent to the uterus, the bulk 
being thereby augmented, the reduction will be the 
more difficult; on the other hand, if you peel off the 
placenta previously to returning the uterus you may 
have to encounter a most frightful haemorrhage, 
which is the greater evil of the two. First make an 
attempt to replace the uterus without separating the 
placenta from it, and if you succeed, so much the 
better ; then by external friction and pressure excite 
the action of the uterus to separate and expel the 
placenta ; but if the difficulty of reduction, while the 
placenta is attached, should prove insurmountable, 
you must then incur the risk of hsemorrhage by first 
separating the placenta, after which the uterus is to 
be returned with all practicable celerity. The same 
rule of practice is to be observed whether the uterus 
remains in the vagina, or protrudes through the os 
externum ; you must, however, in the latter case, 
first return it within the vagina, and press it against 
the os tincse, which constricts it like a ligature ; if 
you push it with violence you will not succeed ; you 
must, "if possible, grasp the whole tumour in your 
hand and steadily compress it; when you find it 
shrink, or contract within the hand, this is the mo- 
ment you are to press it against the os tincse, not 



INVERSION OF THE UTERUS. 291 

upwards and backwards, but in the direction of the 
upper axis of the pelvis, upwards and forwards 
towards the prsecordia; the hand being carried 
through the os uteri into the cavity of the uterus, its 
natural position will be easily restored ; the hand, as 
before directed, must not be withdrawn till it is 
almost expelled by the uterus, or until the uterus is 
firmly contracted. If you neglect this complaint, or 
overlook it, or are called to a patient a few days after 
its occurrence, the reduction of the uterus should 
certainly be attempted. Hunter, Ford, and Den- 
man have failed in this attempt ; but some practi- 
tioners have been more successful. If several days 
have elapsed, it is likely that the uterus will be 
found inflamed, hard and painful to the touch; in 
this state you must not attempt its reduction, as you 
would not only increase the inflammation, but may 
induce convulsions. You must now wait, and have 
recourse to the antiphlogistic treatment, consisting 
of bleeding, purging, low diet, and tepid fomenta- 
tions, together with the recumbent posture : in a few 
days, the inflammation having subsided, the uterus 
becomes soft, and its orifice flaccid, and now you 
must attempt to replace it ; but if many days have 
passed, the probability is, that you will not succeed. 
What will you do in chronic inversion of the uterus ? 
The patient is liable to profuse menorrhagia, and 
leucorrhcea, and her vagina is plugged up ; she suf- 
fers also symptoms of constitutional exhaustion from 
uterine irritation, and the loss of fluids. Tepid 
fomentations must be used for the purposes of clean- 
liness, and astringent lotions, with acid and bitter 
tonics given internally, should be employed to lessen 
the discharge. I fear you will find these remedies 
of little use, for the patient's suffering will end only 
in the grave. The great object will be to palliate 
symptoms as they occur : thus, if the uterus descends, 
it must be supported in the best manner you can ; 



292 DISEASES OF WOMEN AFTER DELIVERY. 

and if there is retention of urine it must be drawn 
oif. It has been proposed in these cases to amputate 
the inverted portion of the uterus : the death of the 
patient is otherwise inevitable, and by this operation 
you may give her chance ; it may save, or it may 
kill her ; there are many cases on record in which 
the uterus has been removed with success.* Some 
time since a case of inversion occurred in which 
several days elapsed before it was discovered; the 
medical men agreed that nothing could be done : the 
patient was sent from London into the country for 
the benefit of the air; the country surgeon, whether 
from boldness or ignorance, put a ligature round the 
neck of the tumour ; in due time the uterus came 
away ; the patient did well, and is now living. A 
medical man had the curiosity to inquire concerning 
the state of her sexual passion, and was informed 
that the loss of the uterus made no difference in this 
respect. 

* A successful case of extirpation of an inverted uterus by Mr. 
Windsor, communicated by Mr. Astley Cooper, is related in 
Med. and Chir. Transactions, vol. x., p. 358 ; also by Dr. Joseph 
Clarke in the Edinburgh Medical and Surg. Journal, vol. ii., 
p. 419; and another case by Mr. Alexander Hunter in Duncan's 
Annals of Medicine for the year 1799, p. 366. 



GENERAL MANAGEMENT OF INFANTS. 293 



LECTURE THE SEVENTH. 



ON THE GENERAL MANAGEMENT, ON THE MALFORMA- 
TIONS AND DISEASES OF INFANTS. 



Section I. — General Management of Infants. 



As soon as the child is born, the function of respi- 
ration most commonly begins, the child gasps, 
inflates its lungs, and cries. Sometimes, however, 
it remains motionless, there is no rising of its chest, 
and it has a livid appearance ; but there is a pulsa- 
tion in the cord, and the heart beats, by which we 
know that the child is alive. In this state, the mus- 
cles of respiration do not act, and the child is in 
danger of being lost from asphyxia. There is great 
reason to believe, when the uterus wholly expels the 
child, that the placenta, in nine cases out of ten, is 
separated by the time the feet are expelled. When 
respiration is not commenced immediately on the 
birth of a child, what are you to do? You must 
excite the action of the respiratory muscles, taking 
care in the meantime that the child's animal heat 
be not lost. These intentions are fulfilled by inflat- 
ing the lungs, and by putting the child into a warm 
bath. During the first five minutes after its birth, 
the heat of the child is not likely to be much dimi- 
nished, therefore first inflate the lungs. This may 
be done either by placing your mouth to that of the 

38 



294 GENERAL MANAGEMENT OF INFANTS. 

infant's, and blowing into it, or by blowing through 
a tube, or by means of a small pair of bellows : the 
first is the readiest mode ; the last the best, for the 
reason that the lungs are then inflated with pure air. 
If you attempt the inflation of the child's lungs 
through its mouth, you first stop both nostrils, and 
press the thyroid cartilage gently back against the 
oesophagus, to prevent the passage of air into the 
stomach. If you employ the bellows, the proceed- 
ing is the same, with the exception that the pipe of 
the bellows is to be adapted to one nostril, while the 
other, as well as the mouth, is closed. The lungs 
are to be inflated slowly, and then press the chest, in 
order to expel the air. These operations are to be 
performed alternately, so as to imitate, as nearly as 
possible, the natural ones of inspiration and expira- 
tion. If in three or four minutes the child does not 
exhibit the customary signs of animation, immerse it 
in a warm bath of ninety-six degrees, and go on 
stimulating the powers of respiration in the manner 
just directed. In five or ten minutes the child will 
generally be restored by this proceeding; but if 
your exertions are not successful within this period, 
you must persevere for half an hour, or you will per- 
haps get into a scrape. A relation of mine was 
delivered of an infant, still-born as they call it: 
means were used to revive it, but without effect ; it 
was given to the nurse to be put aside : some time 
afterwards it began to cry. Smellie relates a simi- 
lar instance. It is by some supposed that respiration 
is performed in these cases, but so feebly as to be 
imperceptible to us. Respiration may sometimes be 
excited by applying stimulants to the child's nostrils; 
a nurse would give it a pinch of snuff; the best 
method is to wet a handkerchief with spirit of am- 
monia, and so hold it that the vapour may ascend 
through the nostrils ; the child gasps and inflates its 
lungs : this will often succeed after other means have 



GENERAL MANAGEMENT OF INFANTS. 295 

failed. If the child has a swollen, red, or livid coun- 
tenance, you had better let it lose a few drachms of 
blood from the funis before tightening the ligature, 
which will relieve congestion about the brain, and 
facilitate respiration. Sometimes the- child is born 
dead, and has manifestly been so many days ; on 
such occasions any proceeding for its recovery is of 
course superfluous. 

As soon as the child is born the mother generally 
asks if it is perfect ? This should be ascertained by 
a general examination ; and if there is any defect or 
malformation, the mother should be now informed of 
it, for she will bear the knowledge of it better at this 
time than afterwards. 

What is the best method of insuring the health of 
infants ? First, let them breathe pure air. Secondly, 
feed them with diet of nature's cooking, the mother's 
milk. Thirdly, keep them religiously clean; and 
by adhering to these directions, you will prevent a 
very large proportion of the diseases of infants. 
Nearly as soon as the child is born, you should di- 
rect a small tea-spoonful of castor oil to be given to 
it, for the purpose of evacuating the meconium. The 
first stools are dark-coloured : in about twenty-four 
hours they become yellow, and of the consistence of 
thin mustard. As long as the child is in health, it 
will have daily two or three of these evacuations. 

There are two modes of rearing children : one by 
hand, as it is termed, the other by the breast ; the 
latter, when the breasts afford an adequate supply of 
milk, is by far the best. Among savages, children 
depend wholly for nourishment on the breast, per- 
haps during the first two or three years. This also 
is not uncommon in civilized life ; but the secretion 
of milk in some females, from feebleness of constitu- 
tion, is not sufficient for the support of the child : or 
the secretion ceases altogether, as from illness after 
labour ; or the time necessary for suckling, in other 



296 GENERAL MANAGEMENT OF INFANTS. 

instances, cannot be spared from the claims of fash- 
ionable life : the child must then be reared on arti- 
ficial food, or by a wet-nurse. Cow's milk contains 
more curd and less sugar than human milk ;* I 
therefore direct an artificial milk, which approaches 
in quality that of the mother, consisting of two-thirds 
of cow's milk, and one-third of water, to which a 
little sugar is to be added. This forms a very good 
substitute, and it should be made fresh as often as 
the child requires it. Biscuit powdered and boiled 
with milk, water, and sugar, is also well suited to 
the delicate stomachs of infants. The French prefer 
diluting cows' milk with an equal quantity of fresh 
whey. Arrow-root, of all vegetables, is the least dis- 
posed to fermentation, and it forms an excellent food, 
either with milk, or with water, and a little sugar. 
In London, if you attempt to rear children by the 
hand, not more than three in twelve will live to be 
two years old. Children should be fed at as regular 
intervals as possible. The periods of nursing ought 
also to be as regularly observed as circumstances will 
admit, and their stomachs should not in either case 
be much filled at once. If it is determined to hire a 
wet-nurse, a woman under thirty should be pre- 
ferred ; her appearance should be perfectly healthy, 
and her temper good, as the secretion of milk is ma- 
terially affected by irritability and passion ; she should 
have large breasts, and a copious supply of milk. It 
will also be of much advantage that the nurse has 
not suckled long previously, and her nipples should 
be sound and well formed ; her diet should be nutri- 
tious, and of the most simple and natural kind. But 
I believe the best method of rearing children when 
their mothers cannot nurse them, is by allowing them 
to suck a domesticated animal. I know a fine healthy 

* Human milk is said to be the lightest known nourishment 
except asses' milk. 



GENERAL MANAGEMENT OF INFANTS. 297 

young lady, now about seventeen years of age, who 
was thus reared. A goat is the best animal for this 
purpose, being easily domesticated, very docile, and 
disposed to an attachment for its foster child : the 
animal lies down, and the child soon knows it well, 
and, when able, makes great efforts to creep away to 
it and suck. Abroad the goat is much used for this 
purpose ; the inhabitants of some villages take in 
children to nurse : the goats, when called, trot away 
to the house ; and each one goes to its child who 
sucks with eagerness, and the children thrive ama- 
zingly. It is very common in this country for people 
to give their children the worst food possible ; this 
consists of flour boiled in milk, which when taken 
into the stomach ferments, and fills the intestinal 
canal with flatus and acidities. If animal food of any 
kind is given to a child during the first nine months, 
it will tend to injure its health. If my patient is not 
able wholly to nourish the child, whether from defi- 
ciency of milk, or delicacy of constitution, I direct 
her to suckle by day, and to feed the child with the 
artificial milk just recommended by night. This 
latter duty may be performed by the nurse, which 
permits the strength of the mother to be renovated 
by unbroken sleep. 

If the child is well, vaccinate it between the first 
and third month after its birth ; never vaccinate from 
dry lymph, when you can use it in a fluid state, which 
will be much more likely to take effect.* In three 
days there will be at the place of the inoculation, if 
it succeeds, an elevated red point, which will gra- 

* Whether the lymph is in a fluid or dry state, it will rarely 
fail to take effect if the point of the lancet is inserted obliquely 
nearly the eighth of an inch under the skin, and suffered to re- 
main there for a minute or two ; the lymph will thus be dissolved ; 
and if the thumb is placed upon the skin, covering the point of 
the lancet while it is withdrawn, the whole of the lymph will be 
wiped off* and retained in the wound. 



298 GENERAL MANAGEMENT OF INFANTS. 

dually increase in size to the eighth day, when there 
will be an elevated but flattened vesicle, with a de- 
pression in the centre, and there should be a bright 
red areola surrounding the whole vesicle. If the 
vesicle is punctured, a thin transparent lymph ex- 
udes, which is in a fit state for use ; by the tenth 
day, the vesicle has become brown and crusty in the 
centre, and the process of scabbing gradually spreads 
to the circumference, so that by the twelfth or four- 
teenth day it is brown and hard all over : in a few 
days more the scab falls off, leaving an indelible 
white scar. Every deviation from these appearances 
is irregular, and as such must be regarded. Vacci- 
nation should be performed in three or four places, 
by way of rendering it as effectual as possible ; and 
one vesicle at least should be allowed to pass through 
all its stages without being punctured. The cow- 
pox is not an infallible preventive of the small-pox : 
if it were, it would be the only thing infallible in 
human nature ; but if it is a preventive in ninety 
cases in a hundred, it must be considered as a very 
valuable resource. In one or two years the security 
of the constitution may be tested by repeating the 
vaccination, or by inoculating with the small-pox 
virus : if there exists a susceptibility to be affected 
by the latter, it is better that the disease should be 
produced by inoculation, than that it should occur 
in the natural way. 



MALFORMATIONS OF INFANTS. 299 



Section II. — Malformations of Infants. 



The treatment of the malformations of infants 
chiefly belongs to the province of surgery ; I shall 
therefore offer upon some of them only a few general 
remarks. 



(a) HARE-LIP. 



"When is the proper time for the operation for the 
hare-lip ? I have seen it done at the end of seven 
weeks after birth with success. I should recommend 
it to be done at the end of three months, when it may 
generally be performed with perfect safety : if, how- 
ever, the malformation is of the worst kind, it should 
be postponed to the end of a twelvemonth. The 
earlier the operation is performed, the less con- 
spicuous will be the scar. The palate is sometimes 
very defective in these cases, and the hare-lip is 
double, as it is termed ; the operation in these in- 
stances is very severe, and the success rarely com- 
plete. The defect is frequently such that the child 
cannot suck ; it must then be nourished by artificial 
food, in the manner formerly directed. 



300 GENERAL MANAGEMENT OF INFANTS. 



(b) DEFECTS OF THE UMBILICUS. 



Protrusion of the bowels, constituting umbilical 
hernia, is of frequent occurrence ; the circular aper- 
ture in the linea alba, through which the vessels of 
the umbilicus pass, is sometimes larger than is na- 
tural, and thus admits the protrusion of the intestines. 
Umbilical hernia generally takes place about two 
months after birth ; the navel should, therefore, be 
compressed up to this time, or even longer ; for a 
hernia in this situation is much more easily prevent- 
ed than cured : however, when detected early, and 
treated in a proper manner, cases of this description 
in general do very well. Your object is to keep the 
protruded parts within the parietes of the abdomen 
for a certain time : if this is effectually done, nature 
will take care, by closing the aperture, that the pro- 
trusion does not again occur. For this purpose, I 
take a conical piece of cork, fold it in linen, and 
place it over the orifice, having first returned the in- 
testine : this compress I prevent from slipping by 
crucial straps of adhesive plaster, and secure the 
whole by a bandage. Bichter's bandage is the best ; 
it is broad and thick in front, and narrow behind. 
A common flannel bandage placed over the sticking- 
plaster will do very well. When the defect is only 
moderate in degree, you may say, if called upon 
for a prognosis, that it will be well in a few weeks. 

The whole abdominal parietes surrounding the 
■umbilicus, including the peritoneum, maybe wanting, 
and the bowels found resting on the thighs of the 



CLOSED LABIA PUDENDI. 301 

child :* this is the worst possible malformation of 
this part : of course it would be irremediable if the 
child were alive ; but in general it is born dead. 



(c) CLOSED LABIA PUDENDI. 



This defect, which occurs occasionally, may in 
general be remedied without the use of the knife ; 
the adhesion being slight, the parts admit of being 
separated by the lingers and thumb. The adhesion 
is, however, sometimes more firm, and requires divi- 
sion by the knife ; the labia are afterwards to be 
kept separated by the introduction of a tent. At 
your first visit after the delivery of your patient 
always make inquiries whether the child has passed 
any water or faeces. 

* I lately met with a case of this kind, but the malformation 
was more extensive : the abdominal parietes were entirely defi- 
cient ; the viscera, which were neither formed nor placed natural- 
ly, were covered only by a thin transparent membrane ; the liver 
was on the left side ; there were no large intestines ; there was 
no bladder ; the left kidney was much larger than the right: in 
the former, and in the ureter connected with it, there was con- 
tained half an ounce of fluid, resembling dark-coloured serum ; 
this fluid was found on analysis to contain uric acid and phosphate 
of lime. There was no appearance either of external or internal 
organs of generation ; neither was there any anus. There was a 
spina bifida at the upper part of the lumbar vertebrae, the cyst of 
which contained five ounces and a half of fluid. The foetus, which 
was dead-born, according to the reckoning of the mother, as well 
as from its appearance, was supposed to be one of between six 
and seven months' growth. — Ed. 



39 



302 MALFORMATIONS OF INFANTS. 



(d) IMPERFORATE URETHRA IN THE MALE INFANT. 



This may be either so slight that the orifice only 
of the urethra is closed by a thin membrane, or by 
small membranous bands, which may be broken 
down by a probe ; or the urethra may be impervious 
to such an extent as to be irremediable. 



(e) IMPERFORATE ANUS. 



The anus, sphincter, and buttocks may be com- 
plete ; yet the gut may be closed by a membrane, 
which will prevent the discharge of faeces ; hence the 
bowels become distended, inflammation and death 
will supervene. If twelve hours pass without any dis- 
charge of meconium, you must examine the parts. 
You pass your little finger, previously oiled, up the 
rectum, and you sometimes distinguish a tense 
membrane closing the gut. When the impediment 
is merely membranous, and near the external parts, 
the defect is easily remedied. Separate the nates; 
and puncture this membrane with a trocar, in the di- 
rection upwards and backwards towards the sacrum, 
and the meconium immediately escapes ; as soon as 
the contents of the bowels are evacuated, you must 
introduce a bougie, which is to be retained, in order 
that the opening may not become closed. If the 
child suffers from irritation, or distension of the 
bowels give it a tepid enema. When the bowels termi- 
nates two or three inches from the anus, you may, if 



IMPERFORATE ANUS. 303 

you can feel the place of the termination of the gut, 
carefully pass up the trocar and puncture ; the oper- 
ation will not in this case be attended with certain 
success ; but a doubtful remedy is sometimes better 
than no remedy at all. In performing the operation 
for imperforate anus, a scalpel or Pott's bistoury may 
be used ; but a trocar, I believe, is sufficient, if you 
are careful not to allow the part to close again, which 
will require considerable attention. The division of 
the membrane must be made with caution. A child 
suffering under this kind of malformation was taken 
to an eminent surgeon ; on introducing his little 
finger he felt the tense membrane, which he punc- 
tured with a trocar, and the meconium escaped ; but, 
not content with this, he took Pott's bistoury, and 
enlarged the wound in the membrane, when more 
meconium came away. The nurse carried the child 
home, and it was the whole way very quiet. She 
thought this a proof of the success of the operation, 
and of the skill of the surgeon, who was capable of 
giving little children so much ease; when she reached 
home the child was found dead, and deluged in blood. 
The surgeon, who could be satisfied only with a large 
opening in the membrane, had wounded one or more 
of the hemorrhoidal arteries. If there is no appear- 
ance of an anus, an incision should be made with a 
scalpel or lancet, half an inch deep, in the situation 
of the natural termination of the rectum ; and if no 
meconium escapes, a trocar may be passed a little 
deeper ; but in the proper direction, backwards 
towards the sacrum ; and the puncture, if successful 
in making a communication with the intestine, should 
be kept open by means of bougies, &c* 

* An artificial anus was first made, by an incision of the colon 
in a child born with an imperforate anus, by M. Duret, a surgeon 
at Brest; the report of this case goes so far as the twenty-fifth 
month, when the child was alive, but suffering from inversion of 
the gut. (See Sabatier's Medicine Operatoire, tome troisieme, 



304 MALFORMATIONS OF INFANTS. 



(f) SPINA BIFIDA. 



This malformation consists in a deficiency of a 
portion of the vertebral column, through which 
opening the membraneous theca of the spinal mar- 
row protrudes, and is covered by the common integu- 
ments. The tumour thus formed is distended with 
a fluid ; in a week or two the part sloughs, and the 
child dies. The tumour varies from the size of a 
walnut to that of a large orange, and occurs generally 
about the lumbar vertebrae : the integument cover- 
ing the part is of a deep red, occasionally with 
patches of a livid colour. The complaint is generally 
a fatal one : it is, therefore, proper to inform the 
parents that the child has a disease, which in all 
probability will destroy it. Sir A. Cooper punc- 
tured a tumour of this kind with a needle and let out 
its contents ; in a few days inflammatory action took 
place in the cyst, adhesion followed, and the child did 

p. 336). It was afterwards performed on a child by Mr. Freer of 
Birmingham, at a time not specified, preceding the year 1817 ; 
this child lived three weeks. It was performed by Mr. Freer on 
an adult in the year 1817. This patient survived the operation 
about nine days. An artificial anus, by incision of the colon, was 
also made by Dr. Pring, of Bath, in the year 1820, in a lady 
sixty-four years of age whose rectum was impervious from scirrhus, 
and who had no evacuation from the bowels for twelve days. 
The operation was, in this case, so far successful, that the patient 
passed her stools from the artificial anus with very little incon- 
venience, for about sixteen months after the operation ; when she 
died from the effects of cancerous disease upon her constitution, 
the rectum being in part thickened, or almost cartilaginous, but in 
great measure destroyed by ulceration and sloughing. See Lond, 
Med. and Phys. Journal, vol. xlv., p. 1, &c. 



CONTORTED FEET, ETC. 305 

well.* In another case of the kind, he returned the 
tumour into the vertebral canal, applied a truss to 
retain it there, and cured the child ; but subsequent 
experience has not confirmed the benefits which 
were anticipated from these modes of practice. 



(g) CONTORTED FEET, ETC. 

Distortions of the extremities generally admit of 
considerable relief from early and well-applied pres- 
sure, by bandages, &c. The foot is sometimes 
turned inwards and sometimes outwards. 

The fingers or toes may at the time of birth be 
either supernumerary or deficient ; or there may be 
pendulous excrescences about the ears and face of 
the child. These supernumerary productions should 
be removed within a week or two after birth. It is 
less easy to supply parts which are deficient. 

* See Observations on Spina Bifida, with Cases, by Sir A. 
Cooper, in Medico-Chirurg. Trans., vol. ii., p. 322. 



306 DISEASES OF INFANTS. 



Section III. — Diseases of Infants. 

(a) DIARRHCEA. 



This complaint is the most common incident to 
children. When the digestive organs are in a 
healthy state the child usually has two or three mo- 
tions in the twenty-four hours, of a golden, or a 
patent-yellow colour, and of the consistence of thin 
mustard. In diarrhoea there is griping, with thin, 
frequent, and green stools. This disease presents 
itself in an infinite variety of degrees : it may soon 
cease, or it may continue for weeks ; in the latter 
case, the child's constitution will suffer greatly : the 
child becomes pale, thin, flabby, and weak, the 
whole system suffering from defective nutrition : 
and if the diarrhoea is not checked the child dies, 
exhausted by intestinal irritation and starvation. 

The treatment is simple : first cleanse the bowels 
well of their unhealthy secretions and other irritating 
matter, — any portion of which, if not effectually 
evacuated, will keep up irritation, and again produce 
purging; this being done, we must soothe irritation, 
neutralize the acids which may arise from a weak- 
ened state of the digestive powers, and restore a 
more healthy action. The cause of this disease must 
be avoided, which is, almost invariably, artificial 
food ill suited to the digestive powers of the infant : 
this is a matter of importance : such food must be 



UIAKRHCEA. 307 

prohibited, and the child must derive its nourish- 
ment exclusively from a full breast of milk. Some 
children, to be sure, are born with the stomachs of 
aldermen, and will digest turtlesoup, or, perhaps, 
even an old slipper. To clear the bowels, give a 
dose of the purest castor oil, or a pow T der composed 
of three grains of rhubarb, the same quantity of mag- 
nesia, and one drop of the oil of aniseed. To soothe 
irritation, and at the same time to correct acidity, 
give the common cretaceous mixture, with a little 
aromatic confection, a dessert-spoonful every three or 
four hours, together with as much tincture of opium 
in the mixture as will amount to a quarter of a drop 
at each dose ; in addition to, or in substitution of, this 
mixture, we shall often have occasion to promote the 
healthy secretions of the alimentary canal, by giving 
small doses of calomel, as two grains of the hydr. 
cum ere ta with three of the compound powder of 
tragacanth, twice or three times a day : this will 
often remove the most obstinate infantile diarrhoea. 
The most important indication in the cure of this 
disease, is the dietetic, improper food being, in 
general, the cause of it. Children are often fed with 
animal food before their stomachs are capable of 
digesting it : this happens most frequently when the 
mother is unable or unwilling to nurse the child, and 
therefore brings it up by hand ; thus the child is 
crammed with gruel, vegetables, tripe, oysters, beef, 
and the Lord knows what. 

After you have tried your remedies in vain, even 
under these circumstances, if possible, get a nurse 
with breasts spouting with milk ; the infantile diar- 
rhoea will speedily be cured, and often in twenty- 
four hours the stools become of the true patent-yellow 
colour. A healthy nurse, who has a plentiful supply 
of milk for the child, effects the most rapid cure. 
This change of diet I have known repeatedly suc- 
cessful after drugs have failed. It sometimes hap- 



308 DISEASES OF INFANTS. 

pens that the child is disordered in its bowels and 
general health, and its body wastes ; on being con- 
sulted, you may represent this state as the conse- 
quence of improper diet ; the stools now appearing 
healthy, you may perhaps be laughed at — but I say, 
do not crow too soon. After a little while, if the 
same food be continued, diarrhoea will come on ; and 
after trying in vain to cork up the bowels by astrin- 
gents, &c., you are at length obliged to abandon 
them for a good breast of milk, when the disease 
will be speedily cured. Often do I see old and 
experienced practitioners, who ought to know better, 
attempting that which is utterly impossible ; wholly 
neglecting this most important point, the diet, and 
giving their useless medicines. I always order the 
child to be nursed on food of nature's cooking, which 
alone is almost invariably attended with success. 



(b) WATERY GRIPES. 



Instead of green stools, the evacuations in this 
complaint are merely coloured water, and are at- 
tended with excessive pain. The child screams, 
and gush comes away the watery motion , it is then 
easy and quiet for a short period ; again the griping 
pain comes on, followed by the evacuation of this 
watery stuff; and in this manner the disease goes 
on, attended with rapid emaciation. So violent is 
this complaint, that children sometimes die of it 
within forty-eight hours from its commencement. If 
you are consulted in the case of a child who is suf- 
fering frequent and griping pains, followed by gushes 
of tinged water from its bowels every half hour, and 
wasting rapidly, you may be assured that it is the 
watery gripes, which resembles diarrhoea, with the 



CHRONIC DIARKHCEA. 309 

exception that it is much more severe, and tends to 
be more rapidly fatal. The first indication is to 
remove any irritating secretions from the bowels, by 
means of a dose of rhubarb or castor oil, either in its 
pure state, or in the form of a mixture or emulsion, 
with some aromatic water ; the next object will be 
to soothe irritation by the use of the warm bath, and 
warm fomentations to the bowels. Give the creta- 
ceous and aromatic mixture, with about the fourth 
of a drop of laudanum in each dose, and also admi- 
nister a starch enema, with a small quantity of 
laudanum, every four hours ; the clysters must be 
injected slowly, to insure their being retained a pro- 
per time, and will be found very effectual in allay- 
ing irritation. The most effectual remedy to relieve 
irritation is a small blister to the prsecordia ; but as 
soon as the cuticle is raised, which is quickly the 
case in young children, take it off, and apply a sim- 
ple dressing. If the blister be allowed to remain on 
beyond the time necessary to produce this effect, 
much mischief will be sometimes occasioned by the 
formation of a deep and troublesome wound. Dr. 
William Hunter used to^say, that nearly all the chil- 
dren whom it was attempted to rear artificially in 
London died of the watery gripes, unless a wet- 
nurse was procured with a full breast of milk. 



(c) CHRONIC DIARRHCEA. 



This complaint is best treated by mild mercurials : 
the hydrargyrum cum creta is a good medicine, 
either alone or with tragacanth, but without opium. 
Starch and anodyne clysters may be administered if 
the symptoms are obstinate. Give to a child of 
about two months old, two grains of hydrarg. cum 

40 



310 DISEASES OF INFANTS. 

creta, with two grains of the compound powder of 
tragacanth, morning and evening : by this medicine 
alone the secretions from the bowels become more 
natural, less in quantity, thicker in consistence, and 
the child's general health is restored. Kino, catechu, 
the infusion of simarouba, and the whole tribe of 
astringents, have been tried : but take away all other 
drugs, and give me mercurial alteratives, together 
with a full breast of milk, and I will cure this disease 
more speedily, and more effectually, than with all 
the other medicines which have been recommended 
put together. I prefer the hydrarg. cum creta to 
calomel : it is much milder. Dr. Clarke used to 
give half a grain of calomel and two grains of mag- 
nesia, every night ; and he said the child would get 
well before it had taken a dozen of these powders. 
It is necessary to ascertain what the diet has been in 
all bowel complaints of children which are difficult 
of cure ; if they have lived upon artificial food, you 
must order it to be discontinued ; a good breast of 
milk should be procured ; if this is not practicable, or 
if the child will not take it, such an artificial diet is 
to be prescribed as was formerly recommended, and 
persevered in with great steadiness.* 



(d) convulsions. 



The nervous system of infants is very susceptible 
of irritation : hence they are predisposed to convul- 
sions, characterized by insensibility, violent agitation 
of the limbs and trunk, sometimes foaming at the 
mouth, distorted features, dilated pupils, &c. Con- 

* The advantage of sucking the food from a teapot or bottle, 
by which the saliva is mixed with it, is by some insisted upon. 






CONVULSIONS. 311 

vulsions sometimes precede hydrocephalus, or occur 
as a symptom in the progress of this complaint; 
they are also symptomatic of some of the eruptive 
diseases, particularly of the small-pox. Convulsions 
are often produced by irritation in the alimentary 
canal, and are occasionally attendant on the progress 
of dentition. If the convulsive fits occur during the 
first four or five months, you will generally find, on 
inquiry, that the child's bowels have been disordered 
some days previously; the tongue is furred, and 
there is a febrile state of the system. Remove the 
exciting cause of the disorder of the alimentary 
canal, and the irritation of the nervous system will 
cease. Your object must, therefore, be to procure 
copious evacuations from the bowels; if a brisk 
purge of calomel and jalap can be administered, it 
will speedily operate ; but, as the teeth are firmly 
clenched, this will not be done without difficulty. 
An enema carefully thrown up will frequently have 
the effect of procuring free evacuations, and in a 
few minutes the convulsions will cease. 

Should convulsions occur after the sixth month, 
dentition may be suspected, as the exciting cause : 
you must, however, make yourself acquainted with 
these particulars by proper inquiries. If, on examina- 
tion, you perceive the gum raised, hot, and swollen, 
it is very probable that the convulsions are owing 
to the irritation thus produced. In this case, the 
gum must be laid open down to the tooth, which 
will sometimes relieve the child immediately ; after 
which, attend to the bowels. Although the child's 
bowels may be open every day, yet there may be 
some irritating matter still remaining in them; it 
will, therefore, be proper to give an active purgative 
of calomel and jalap, or of the compound powder of 
scammony, together with an enema, wmich should 
be thrown up slowly : for if done suddenly or vio- 
lently it will be introduced with difficulty, and 



312 DISEASES OF INFANTS. 

immediately rejected. The child should also be 
immersed for ten minutes in a warm bath at 96°, in 
order to tranquillize the nervous system. After 
these means have been employed, and the bowels 
have been freely evacuated, give some antispas- 
modic, if necessary ; the best is the spiritus ammo- 
nise foetidus, three drops of which may be given, in 
a little dill water, every four hours : the tincture of 
castor is also a good antispasmodic. In the treat- 
ment of the convulsions of infants, these are the most 
useful means ; among which, the exhibition of an 
effectual purgative is of the greatest importance. If 
the child is of a plethoric habit, or shows any symp- 
tom of cerebral congestion, apply a leech or two 
behind each ear : the brain is seldom so much irri- 
tated as to occasion convulsions without more or less 
of vascular congestion : this must be borne in mind ; 
and if the convulsions do not readily yield to the 
before-mentioned treatment, take away a small quan- 
tity of blood, by cupping at the back of the neck, or 
by leeches applied behind the ears, or on the tem- 
ples. If the child is two months old, the loss of two 
or three drachms will be sufficient ; if four or five 
months old, an ounce may be taken ; making the 
quantity depend upon the age and habit of the child. 
Children manufacture blood slowly ; therefore, just 
take away enough to diminish the existing conges- 
tion. I lately visited a child which was much con- 
vulsed ; I inquired of the nurse how its bowels were. 
"Oh, quite regular: a motion every day." I 
gradually threw up an enema; in a few minutes it 
brought away a large quantity of faeces, and the con- 
vulsions immediately ceased ; the child looked about, 
and had no relapse. 



DISORDERS CONNECTED WITH DENTITION. 313 



(e) DISORDERS CONNECTED WITH DENTITION. 



In about six months from its birth, an infant be- 
gins to suffer from the natural process of teething ; 
and although a child may have been previously 
healthy, this process often makes it puny and sickly : 
but dentition being over, the child again exhibits the 
customary appearances of health. Children are some- 
times, though very rarely, born with teeth, or with 
one tooth. The process of dentition is in general 
commenced at about the sixth or seventh month, and 
it is over about the end of the second year. These 
primary teeth appear in couples, and about a month 
or six weeks commonly intervenes between each 
couple ; the two middle incisors of the lower jaw ap- 
pear first, then corresponding ones of the upper jaw, 
next the remaining incisors, those of the lower jaw 
first, though not invariably. Two or three months 
elapse, but the period varies, when next in succes- 
sion four of the anterior molares appear ; at length, 
after a longer interval, the cuspid ati come through ; 
and after another interval of a few months, the pos- 
terior molares ; when, about the expiration of two 
years, the number of the deciduous or milk teeth is 
complete. These remain until about the sixth or 
seventh year, when the shedding of the primary 
teeth commences, and they give place to others which 
are permanent. Twenty are the usual number of 
the first set, or milk teeth, as they are called, ten in 
each jaw. The permanent or adult teeth consist of 
from twenty-eight to thirty-two. How do you know 
the child is teething ? By the obvious signs of irri- 



314 DISEASES OF INFANTS. 

tation and disturbance about the mouth and gums ; 
the child keeps its finger in its mouth, the gums are 
swollen, and it drivels saliva profusely : it is feverish, 
has no appetite, is peevish and fretful, and it screams 
and starts suddenly without any apparent reason, by 
night and by day, and takes but short naps of sleep : 
if °at five or six months after birth a child is thus af- 
fected, you may conclude that dentition has begun. 
What are you to do? When these symptoms are 
but slight, you have little or nothing to do ; the only 
particulars to be attended to are the child's diet and 
bowels : the former should be of the least stimulating 
quality ^ and the latter should be kept gently relaxed. 
This simple treatment will often carry the child 
through this 'period with very little disturbance of 
its constitution. 

But worse symptoms sometimes occur ; there is 
great disorder of the digestive organs, with perhaps 
diarrhoea, accompanied with a high degree of fever, 
all arising from irritation of the gums. The diarrhoea 
is nature^s mode of obviating more violent inflamma- 
tory action in other vital organs ; but this state may 
become chronic, or, from its severity, may so effect 
the constitution as to endanger the child's life. Irri- 
tation of the brain may occur during dentition, giving 
rise to convulsions ; and sometimes chronic pulmo- 
nary inflammation is produced, which resists all the 
common remedies. In the treatment of these affec- 
tions, when they appear to be induced by teething, 
there is one general aphorism : use the same reme- 
dies in either case as would be indicated under simi- 
lar circumstances when the disease arises from other 
causes ; but, in addition, take care to let the tooth 
through as soon as you can. If the fever should run 
high, if the skin is very hot, the pulse rapid, and the 
child drowsy, give it a gentle emetic, and a brisk 
purge of calomel, jalap, and scammony ; put the child 



DISORDERS CONNECTED WITH DENTITION. 315 

into a warm bath of ninety-six degrees eight or ten 
minutes; and lance the swollen gum. 

The teeth grow two ways : first, laterally • in this 
manner they increase in breadth : this is attended 
with drivelling of saliva, but with little irritation ; 
there is no elevation of the gum, and consequently no 
occasion for the lancet. They also grow upwards ; 
the upper part of the gum becomes elevated and 
rounded ; and the narrow seam or ridge on its upper 
surface will disappear, if the tooth is approaching 
near the surface ; this is the proper time for lancing 
the gum, when, if sufficiently advanced, the tooth 
will make its appearance through in twenty-four 
hours. The benefit to be derived from lancing the 
gums depends entirely on your cutting through the 
capsule of the tooth ; you must therefore make the 
incision until your instrument grates on the tooth; 
it must not be done superficially ; but cut deliber- 
ately down on the tooth, and make a crucial incision. 
When the teeth are increasing laterally, the child 
will frequently rub its gums with its fingers, or any- 
thing that may be put into its hand ; but when the 
gum is much elevated and irritable, the child will 
not suffer anything to touch the part, as the gum is 
tense over the tooth, and susceptible of great pain on 
pressure. 

If convulsions supervene, you form your conclu- 
sion whether they are occasioned by teething, or by 
a disordered state of the bowels, by the age of the 
child : if they occur before the fifth month, the pro- 
bability is that the bowels are mainly at fault; if 
about the usual period when dentition has begun, it 
is equally probable that this is the cause, with which 
also a disordered state of the bowels may co-operate. 
Here you must never neglect to give purgatives so 
as thoroughly to cleanse the bowels ; lance the gums 
if necessary; and put the child into a warm bath, 
and employ the means before spoken of when treating 



316 DISEASES OF INFANTS. 

of convulsions. Chronic diarrhoea sometimes comes 
on during the progress of dentition ; irritation of the 
gums is the cause, and this affection continues until 
the tooth comes through ; it then gets better ; but it 
occasionally happens that before the child has time 
to rally, and recover from the effects of cutting one 
tooth, another is about to come through, and the dis- 
ease may be thus repeatedly aggravated. In this 
case the gum is to be lanced, and the diarrhoea 
treated upon general principles. Some practitioners 
give powerful astringents which suppress the diar- 
rhoea and produce costiveness, which is highly pre- 
judicial ; a febrile state of the system will most pro- 
bably ensue, together with a violent and dangerous 
excitement of the brain. The best mode of treat- 
ment is to let the tooth through by lancing the gum 
as soon as it is practicable : keep the child, if weaned, 
on unstimulating diet, as gruel, tapioca, arrow-root, 
&c, and do not at first check the purging, but give 
a tea-spoonful of castor oil, together with such reme- 
dies as will improve the secretions, as hydrarg. cum 
creta, or small doses of calomel with a minute quan- 
tity of opium, twice a day : these at first are the 
best remedies ; mild astringents may afterwards be 
given, as the infusion of simarouba, or the pulvis 
cretae com p. 

Sometimes during the process of dentition, in con- 
sequence of long-continued disorder of the stomach 
and bowels, a febrile state of the system is induced, 
which I think may be properly designated as in- 
fantile hectic fever ; relief in these cases is derived 
from those means before mentioned, which tend to 
alter and improve the unhealthy secretions of the 
alimentary canal : at the same time, it must not be 
forgotten to obviate the primary and chief cause of 
the irritation by lancing the gums. The child's 
diet should consist solely of milk from the breast, 



DISORDERS CONNECTED WITH DENTITION. 317 

when practicable ; or, if already weaned, of food of a 
nourishing, but unstimulating quality. 

Chronic, bronchial, or pulmonic inflammation is 
not unfrequently excited by the local irritation of 
teething : this is accompanied with fever, frequent 
and distressing cough, hoarseness, and difficulty of 
breathing. If these symptoms do not readily yield 
to remedies commonly employed in such affections 
of the chest, examine the gums, which you will 
sometimes find swollen and painful : in this case the 
gum must be lanced as soon as possible, and the 
symptoms of pulmonic inflammation treated as if 
arising from any other cause, by ipecacuanha, calo- 
mel, jalap, &c. ; and one or two leeches may be ap- 
plied to the chest if necessary. 

Various cutaneous affections frequently occur 
about the time of the commencement of dentition, 
and continue during this process. Excoriations, &c, 
behind the ears and about the face are also not un- 
common, all of which quickly get well when the 
tooth makes its way through the gum. In all dis- 
eases of dentition, obviate the cause by lancing the 
gum as early as it can be done with propriety, and 
proceed to treat each disease as you would under 
other circumstances, on general principles. 

When will it be proper to wean the child ? This 
must depend on circumstances, both as regards the 
mother and child. The stomach, in general, is capa- 
ble of digesting artificial food soon after the appear- 
ance of the teeth, which will be about the end of the 
sixth or seventh month : it is, however, better, if 
possible, to wait until eight or nine months have 
elapsed before the child is fed entirely on artificial 
diet. Many women are desirous of suckling for a 
much longer period, perhaps for eighteen or twenty 
months, to the risk or injury of their own health. It 
is well known that women, when suckling, do not, 
in general, become pregnant ; for as long as the men- 

41 



318 DISEASES OF INFANTS. 

strual function is not so regularly performed by the 
uterus, it will not so readily perform its conceptive 
function; for this reason women sometimes go on 
nursing their children long after their stomachs are 
equal to the digestion of artificial food. The age of 
nine months is a very good time to wean the child, 
as its artificial food will, in general, at this time be 
properly digested. But, even at nine months, the 
digestive organs of some children are in so irritable 
and debilitated a state, that if any other food is sub- 
stituted for the mother's milk, numerous evils of in- 
digestion follow ; the bowels become disordered, the 
secretions unhealthy, and the child may die from 
diarrhoea or convulsions. When this state of the 
system occurs, endeavour to remedy it by medical 
treatment as before directed ; if you do not succeed, 
allow the child to suck the mother or a wet-nurse 
three or four months longer, or until its stomach shall 
have acquired sufficient strength to digest artificial 
food. 



(f) INFANTILE REMITTENT FEVER. 



Children are liable to this disease from the age of 
one year to that of twelve years. The child thus 
affected loses its appetite, grows pale, thin, and weak ; 
he is hot and feverish at one part of the day, drowsy 
and peevish at another ; sometimes cool and playful ; 
but still never free from the symptoms of fever. The 
child's bowels are disordered, and the appearance of 
the evacuations is anything but natural. This state of 
things may go on for two or three months. The 
little patient first manifests pain about the head, then 
total loss of appetite ; the pulse is rapid, and the 
tongue covered with a brownish coat; the evacua- 



INFANTILE REMITTENT FEVER. 319 

tions from the bowels are black, clay-coloured, or 
curdled : sometimes, in the course of this complaint, 
the bowels are constipated. In addition to these 
symptoms, the child has an irresistible propensity to 
pick its lips, nose, fingers, or some part of its body : 
these places will bleed or, perhaps, even become 
ulcers. This is the remittent fever ; and it may con- 
tinue for six, eight, or even twelve weeks. The 
common opinion as to its cause is, that the constitu- 
tion becomes thus affected from a disordered state of 
the alimentary canal, the origin of which may be 
traced to some indigestible artificial food. But I be- 
lieve, it is difficult to say, in many of these cases, 
whether the belly disorders the body, or the body the 
belly. Be that as it may, there is evident constitu- 
tional affection, with disordered bowels. We must 
apply our remedies to the part most susceptible of 
their action ; and I am inclined to say, take care of 
the disordered bowels, and let the body take care of 
itself : therefore, first endeavour to restore the health 
of the digestive organs, and that of the constitution 
will follow. Dr. Butter, whose treatise on this sub- 
ject is worth reading, proposes two remedies ; these 
are simple saline laxatives, and mercurial alteratives : 
he gives one drachm of the sulphate of potash, in 
twenty-four hours, in divided doses, diminishing or 
increasing the quantity according to the effect pro- 
duced, which should be about four evacuations daily, 
together with small alterative doses of mercury. By 
this treatment the bowels get into a better state : and 
when they have been well cleansed he gives some 
simple tonic, as a mineral acid, cascarilla, or canella 
alba. The powder I am in the habit of directing to 
be given, every night and morning, consists of 
hydrarg. submur., gr. j. ; soda carbon, exsic. gr., iv. ; 
creta, gr. ij. : this powder generally succeeds in pro- 
curing three or four evacuations a day from the 
bowels ; the secretions become more natural in ap- 



320 DISEASES OF INFANTS. 

pearance, and the child's health improves. If indi- 
cated by circumstances, I give in addition, now and 
then, a more brisk purgative. Parents very gene- 
rally think their children are to be well in twenty- 
four hours after having sent .for a medical man; but 
you must give a guarded prognosis, by which they 
will be led to expect that the disease may be linger- 
ing : you may say it is a disease slow in its progress, 
and that, like the small-pox or measles, it has a 
natural tendency to run a coarse, varying in dura- 
tion from fourteen days to several weeks. 



(g) CROUP. 



This disease is most frequently induced by a cold 
and damp atmosphere. It first comes on with a 
little cough, hoarseness, and fever, arfd resembles a 
common cold ; in two or three days, there is a pecu- 
liar sound when the child coughs, somewhat similar 
to the crowing of a young cock ; the pulse is fre- 
quent, and, during the intervals of the cough, the 
child breathes with difficulty. All these symptoms, 
if not arrested, rapidly get worse; the circulation 
through the lungs is impeded, the countenance be- 
comes livid and turgid, and the fingers and nails 
purple ; the extremities are cold, and the child soon 
dies from suffocation. On examination after death, 
the trachea appears as if lined by a new membrane, 
and entirely plugged up by viscid lymph; on remov- 
ing this adventitious coat of lymph, the inner mem- 
brane of the trachea appears highly injected with 
blood. This malady generally runs its course in 
five or six days, and, if not actively treated, will 
sometimes prove fatal in one or two. When the 
disease is once established, some practitioners have 



CROUP. 321 

said they have never seen an instance of its being 
cured, whilst others profess to cure it infallibly in its 
early stage. The disease is an inflammation of the 
trachea, with effusion of eoagulable lymph from the 
distended vessels of its inner surface. When called 
to a patient suffering under symptoms of this com- 
plaint, give a few grains of ipecacuanha as soon as 
possible, and repeat the dose every ten minutes, till 
full vomiting is produced ; frequently, by this sim- 
ple remedy the symptoms are relieved, the progress 
of the disease is arrested, and, with a little subse- 
quent care, the child recovers. The child is some- 
times at once relieved by bringing up, during the 
action of an emetic, shreds of membrane, or flakes of 
lymph ; but, in some cases, the first excitement of 
vomiting gives no relief of symptoms; the nausea 
and vomiting must then be kept up ; in other 
instances, the disease may at first be relieved by an 
emetic, and then return in its former degree, when 
we must again have recourse to the same means. If, 
however, vomiting does not afford decided relief, we 
must abstract blood without delay ; give purgatives 
and calomel. The abstraction of blood should be 
such as to produce a decided influence on the circu- 
lation. If the age of the child will permit a general 
bleeding, open the jugular vein, if possible, or else 
take blood from the arm ; by this depletion, the 
child's pulse, which was quick, strong, and throb- 
bing, should be rendered feeble and languid. If 
faintness takes place, do not attempt to shorten its 
duration, but rather endeavour to keep the circula- 
tion in this languid state for some little time ; if 
necessary we must bleed again, or apply a few 
leeches to the throat. When the child is very young, 
four or six leeches to the throat will abstract as much 
blood as the system will bear ; and the effect of the 
oozing from the leech-bites must be watched, or the 
circulation may be drained until life becomes extinct. 



322 DISEASES OF INFANTS. 

Having reduced the circulation by bleeding, give 
calomel ; it has been satisfactorily shown, by expe- 
rience, that this medicine, after bleeding, possesses 
the power of a specific in subduing active inflamma- 
tion of certain parts, as the iris, liver, &,c. In croup, 
which is a disease tending rapidly to a fatal termina- 
tion, it must be given in large and frequent doses, so 
as speedily to affect the system, as three grains every 
four hours, until two effects are produced ; namely, 
frequent and copious evacuations of unhealthy secre- 
tions from the bowels ; and a relief of the difficulty 
of respiration. These effects being produced, the 
calomel is to be discontinued; and the treatment 
afterwards will consist only in the exhibition of sim- 
ple purgatives. After depletion, counter-irritation 
may be excited by a blister on the chest ; the warm 
bath also may be employed ; but I rely on vomiting, 
purging, the abstraction of blood, and calomel. 



(h) SPASMODIC CROUP. 



There are diseases which resemble croup. My 
son had been ailing a few days, refusing his food ; he 
was a little feverish, and his cheeks high coloured. 
One night the nurse brought him to me, thinking 
him almost suffocated : when he spoke or coughed 
it was with a noise resembling that of croup ; but it 
was remarkable that his circulation was perfectly 
tranquil, and at times during five minutes together 
he breathed easily. The difference between this 
affection and croup is, that in this disease the circu- 
lation is not materially increased, and the respiration 
is alternately difficult and easy. By giving my little 
boy small doses of ipecacuanha wine at frequent 
intervals, till copious vomiting was produced, and 



SPASMODIC CROUP. 323 

by the use of the warm bath, the symptoms were 
soon relieved, and their return was prevented by 
continuing small doses of ipecacuanha at longer in- 
tervals. 

There is a singular affection, in which the respira- 
tory organs participate, which is sometimes met with 
in children; though I believe it has never been 
regularly described. I know of no name for it more 
appropriate than that of child-crowing. The child's 
health appears good; it may, perhaps, indicate a 
desire for something ; and being denied it, or from 
any other cause of slight irritation, it suddenly 
throws itself backwards in the nurse's lap, and makes 
a peculiar noise, caused by very short inspirations. 
This continues a few moments only, and with a full 
inspiration it goes off; this occurs several times a 
day, and apparently from slight causes. You may 
at first, perhaps, consider this complaint of little or 
no consequence, and may think to cure it in a week ; 
but it will, perhaps, continue for a month, or even 
longer ; and in some instances the child's thumbs 
are drawn in on the palms of the hands, and it is 
attended with convulsions. You might also think it 
merely a disorder of the respiratory organs ; but as 
spasm evidently accompanies it, and as it often goes 
on to convulsions, it seems to me more probably an 
affection of the brain. It is a disease of fatal ten- 
dency ; about one-third of those attacked with it die. 
What are you to do? As far as I know, all medical 
treatment is unavailing. Children are disposed to 
this affection during dentition. If it does happen 
during this period, examine the gums, and let any 
teeth through that may appear to require it ; watch 
well the state of the stomach and bowels, give anti- 
monials for the relief of spasm, together with from 
ten to twenty drops of the tincture of castor every 
six hours. When there is manifest congestion of 
the brain, convulsions will follow, if this state is not 



324 DISEASES OF INFANTS. 

relieved by purging, and the abstraction of blood, 
either by leeches or cupping. This disease may 
even continue for several months : you must attend 
to the functions of the digestive organs, give anti- 
spasmodics, and obviate congestion about the head 
by bleeding, &c, whether convulsions are present or 
not. By sending children affected with this com- 
plaint out of town into a mild and healthy atmo- 
sphere, I have known several cured without the aid 
of medicine, and they have had no relapse. But 
you must not fancy that this disease is peculiar to 
towns, for I have known children brought from the 
country, and I have visited others in the country, who 
have been suffering under it. On the other hand, 
although country air is not a preventive, yet I have 
seen wonderful benefit in this disease from change of 
air ; and it is the best remedy I am acquainted with 
for this as well as many other infantile diseases. But in 
some of these cases nothing does good, and the child 
dies ; and the appearances of the brain on dissection 
show that vascular congestion has existed, which 
has ended in effusion into the ventricles, and death. 
If, therefore, you inform the parents of children thus 
affected that the disease is harmless, you will some- 
times get into difficulties; you must, in this, as in 
many other complaints, give a guarded prognosis. 



INDEX. 



A. 

Abdomen, first perceptible enlargement of, in pregnancy, 100. 
Abortion, 122. 

varieties of, 123. 
causes of, 123. 

what females most disposed to, 125. 
prevention of, 126. 

common with those who have painful menstruation, 127. 
prevention of, 128. 
treatment of, 129. 
haemorrhage in, prevention of, 130. 
extraction of placenta in, 131. 
Abscess, mammary, or milk, causes and symptoms of, 264. 

treatment of, 264. 
whether to be opened, 265. 
sinuses after, treatment of, 266. 
After-pains, 255. 

Air, change of, advantages of, in diseases of children, 324. 
Anus, imperforate, 302. 

varieties and treatment of, 303. 
operations for, 303. 
Arm, presentation of, position of the child in, 222. 
how ascertained, 222. 

with the head resting on the brim of the pelvis, 222. 
mode of treatment of varieties, 224. 
queries relating to the stages of, 226. 

B. 

Bleeding in puerperal fever, 272. 
Blisters on infants not to remain on long, 309. 
Blood, formed slowly by children, 312. 
transfusion of, note on, 238. 
42 



326 INDEX. 

Breech, presentation of, 219. 

how known, 220. 
delivery how facilitated in, 220. 
position of the child in, 220. 
connected with a narrow pelvis, 220. 

ascertained deformity of pelvis, 221. 
danger of using force in cases of, 221. 
delivery of the head in difficult cases of, 221 . 

C. 

Caesarean section, why performed, 214. 

how often performed, 215. 
how performed, 215. 
consequences of, 216. 
Calomel and opium in puerperal fever, 274. 
Catheter, female, introduction of, note on, 119. 
Child, position of, in utero, 98. 

to be entirely expelled by the uterus, 147. 
whether more than one, when to be ascertained, 147. 
when to be applied to the breast, 256. 
how often to be nursed, 264. 
Children, plurality of, 245. 

how best reared artificially, 295, 296. 
reared artificially in London, commonly die, 296. 
when to be weaned, 314. 
Child-crowing, 323. 

fatal tendency of, 323. 
treatment of, 323. 
Chlorosis, 18. 

symptoms of, 18. 
pathology of, 18. 
terminations of, 20. 
treatment of, 20. 
Conception, theory of, 78. 

supposed proof of, 81. 
not prevented by hemiplegia, 84. 
it is said may take place during sleep, 85. 
Convulsions, puerperal, 230. 

connection of, with labour, 231. 

differ from epilepsy, 231. 

examinations after death in cases of, 231. 

females disposed to, 231. 

causes of, 232. 

treatment of, 232. 

bleeding in, 232. 

delivery in, 233. 



INDEX. 327 

Convulsions, puerperal, at the sixth or seventh month of preg- 
nancy, 234. 
delivery in, not sufficient, 235. 
cold affusion in, 235. 
state of the heart after death from, 236. 
likely to be followed by peritonitis, 236. 
camphor in, 236. 
of infants, symptoms of, 310. 

causes and treatment of, 311, 312. 
bleeding for the relief or cure of, 312. 
in children, connected with dentition, 313. 
Copulation, what degree of, necessary to impregnation, 85. 
Corpora lutea, 86. 

in twin cases, 87. 
Corpus luteum, 90. 
Cord, umbilical, management of, in footling cases, 219. 

compression of, how indicated, 219. 
Costiveness during pregnancy, 112. 

tendency to, during pregnancy, 257. 
Cow-pox, progress of, after vaccination, 298. 

how far preventive of small-pox, 298. 
Craniotomy, 206. 

when necessary, 209. 

how performed, 209. 

extraction of the child after, 210. 

forceps for, 210. 
Crotchet, use of, 210. 
Croup, cause and symptoms of, 320. 

examinations after death from, 320. 
treatment of, 321. 

by bleeding and calomel, 321. 
spasmodic, 322. 

D. 

Dentition, disorders connected with, 313. 
general account of, 313. 
progress of, 313. 
symptoms of 314. 
treatment of, 316. 

diarrhoea during, when beneficial, 316. 
diseases produced by, 317. 

treatment of, 317. 
treatment of diarrhoea connected with, 316. 
infantile hectic fever connected with, 316. 
chronic pulmonary inflammation connected with, 317. 
cutaneous affections connected with, 317. 



328 INDEX. 

Diarrhoea of infants, 306. 

treatment and cause of, 306. 
advantage of wet nurse in, 307. 
chronic, of infants, symptoms and treatment of, 309. 
Diet after parturition, 256. 

of infants, importance of, 307, 
Diseases of infants, 306. 
Dropsy, ovarian, 74. 

in connection with labour, 186, 
Dysmenorrhea, 29, 127. 

symptoms of, 29. 
forms of, 30, 
treatment of, 30. 

E. 

Evolution, spontaneous, 224. 

though possible not to be waited for, 225. 
Exhaustion during labour, 191. 
Expulsion of the child, how accomplished, 136. 

F. 

Face, presentation of, 188. 

Fallopian tubes, effects of division of, 83. 

will not admit air impelled from the uterus, 84. 
Feet presentation of, 218. 

proper position of the head in, 218. 

how ascertained, 218. 
contorted, 305. 
Fever, puerperal, or child-bed, mortality from, 267. 
capricious occurrence of, 267. 
symptoms 6f, 268. 
stages of, 268. 

appearances after death from, 269. 
origin of, 269. 
whether infectious, 270. 
treatment of, 271. 

to be decisive and speedy, 272. 
loaded bowels a frequent cause of sporadic cases 
of, 273. 
infantile remittent, symptoms of, 318. 

causes and treatment of, 318, 319. 
Fingers and toes, supernumerary, in infants, 305. 
Flooding after the birth of the child, 153, 157. 
Fluor albus, 40. 
Foetus, anatomical peculiarities of, 95. 

how ascertained whether born alive, 95, 
circulation of, 96. 



INDEX. 329 

Food for infants, pernicious, 297. 

of infants a common cause of diarrhcea, 307. 
of infants to be sucked, note, 310. 
Footling cases, management of, 218, 
Forceps, history of, 192. 

on the employment of, 193. 

dangers from employment of, 195. 

how to be applied, 197. 

how to be employed in extraction, 197. 

when to be used, 202, 203. 

to be used with caution when the os uteri is not fully 

dilated, 209. 
long, when to be used, 209. 
how to be applied, 209. 
Fungus uteri, ligature on, prejudicial, 61. 
Funis umbilicalis, anatomy of, 93. 
length of, 93. 
around the neck of the child, 147. 
division of, 148. 

the eyes to be employed in, 148. 
danger of breaking, in extracting the placenta, 150. 
presentation of, how known, 228. 
danger of, 228. 
modes of treatment in, 229. 
in presentation of, how to be returned and kept up, 229. 
Furor uterinus, 47. 

treatment of, 4*8. 

G. 

Goats employed for suckling children, 296, 297. 
Gums, when to be lanced, 315. 
how to be lanced, 315, 

H. 

Hare-lip, 299. 

Head, shape of child's, relatively to the pelvis, 140. 
child's, dimensions of, 182. 

impeded labour, by enlargement of, 186. 

unnatural position of, 197. 

opening of the, 207. 

when to be opened, 208. 

how to be extracted when separated from the body, 
221, note. 
Heart-burn during pregnancy, 111. 



I 



330 INDEX. 

Hemorrhage, uterine, after the birth of the child, 153. 
internal, 154. 

signs of, 156. 
of fainting from, 156. 
after the birth of the child, treatment of, 157. 
pressure in, 158. 
application of cold in, 161. 
pressure and cold the most powerful remedies in, 

162. 
vinegar plugs in, 167. 
application of vinegar to the uterus in, 167. 
effects of, upon the constitution, 168. 
of syncope from, 168. 

treatment of, 168. 
before the birth of the child, 236. 

causes of, 237. 
how produced by the attachment of the placenta 

over the os uteri, 237. 
varieties of, 237. 

treatment of, 238. 
moderate treatment of, 238. 
moderate, benefits of nitre in, 238. 
delivery how accomplished in cases of, 239. 
mode of delivery in common cases of, 240. 
from placenta presentation, mode of delivery in cases 

of, 240, 241, 242. 
should not be suffered to proceed so far as to endan- 
ger life, 239. 
to be watched assiduously, 239. 
effect of, in relaxing the os uteri, 239. 
continuing after the rupture of the membranes, 245. 
general rule for treatment of cases of, 245. 
Hernia, umbilical, in infants, 300. 

treatment of, 300. 
Hour-glass contraction of the uterus, 163. 

I. 

Impaction of the head, a cause of inflammation and sloughing, 

190. 
Imperforate hymen, 48. 
Imperforate hymen, symptoms of, 49. 
treatment of, 50. 
Impregnation, anatomical changes succeeding to, 86. 
Infant, whether perfect, to be ascertained at the time of its birth, 

295. 



INDEX. 331 

Infants, general management of, 293. 

commencement of respiration of, 293. 

how to be excited, 293. 

best means of insuring the health of, 295. 

healthy stools of, 295. 

how reared, 295. 

artificially, 296. 

vaccination of, 297. 

malformations of, 299. 

diseases of, 306. 

stools of, 306. 
Inversion of the uterus, 286. 



Labia, enlarged during pregnancy, 114. 
pudendi, closed in infants, 301. 
Labour, premature, 122. 

symptoms preceding the commencement of, 133. 

symptoms of the commencement of, 134. 

period of, 132. 

natural, 132. 

progress of, 133. 

commencement of, how to be ascertained, 141. 

management required during, 142. 

dilatation of the os uteri, during, 145. 

progress of, 145. 

on difficult, 173. 

impeded, 174. 

causes of, 174. 
debility a cause of, 175. 
irregular action of the uterus a cause of, 176. 
by contraction of the soft parts, 178. 
thickened os uteri, 180. 
tumours, 185. 

the size of the child's head, 187. 
unnatural position of the child's head, 188. 
protracted, injuries arising from, 189. 
exhaustion from, 190. 
dangers from, 191. 

different proceedings required in the varieties 
of, 191. 
artificial premature, 211. 

at what period to be produced, 211. 

how produced, 212. 

dangers of, 213. 

number of children saved by, 213. 



332 INDEX. 

Labour, deviations from natural, requiring the interference of 
art, 229. 
complicated 230. 

the recumbent position to be preserved after, 254. 
retention of urine after, 254. 
purgative to be given third day after, 257. 
Leech-bites, bleeding from, in children, to be watched, 321. 
Leucorrhcea, 40. 

symptoms of, 41. 
seat of, 41. 
treatment of, 42. 
Liquor amnii, 91. 

abortion succeeds the eseape of, 94. 
importance of, at the time of labour, 94. 
Lungs, inflation of, in infants born in a state of asphyxia, 293. 

M. 

Malformation of infants, 299. 
Mania, puerperal, symptoms of, 277. 
prognosis in, 277. 
mischievous propensities of patients suffering, 

277. 
purgatives in, 280. 
bleeding in, 279. 
whether to be prevented, 280. 
treatment of, 280. 
patients suffering under, not to be disputed 

with, 281. 
case of, 281. 

occurring after convulsions usually fatal, 282. 
Meconium,, 98. 

Membranes not to be ruptured till the os uteri is fully dilated, 177. 
rupture of, to induce premature labour, 213. 

interval after, before labour commences, 213. 
Menorrhagia, 32. 

symptoms of, 33. 
forms of, 34. 
treatment of, 35. 
diseases connected with, 39. 
Menses, final cessation of, 44. 
treatment of, 44. 
Menstrual secretion, seat of, 15. 

quantity of, 16. 

nature of, 16. 

supposed qualities of, 17. 



index. 333 

Menstruation, 13. 

first occurrence, 14 
symptoms preceding, 14. 
cause of, 15. 
period of, 17. 
obstructed, 27. 

treatment of, 28. 
painful, 29. 
profuse, 39. 
during pregnancy, 107. 
Mercury, proper in one form of dysmenorrhea, 70. 
Milk, when first secreted, 256. 

fluid nourishment most favourable to the formation of, 259. 
how to be diminished, 259. 

escape of, best promoted by warm applications, 260. 
artificial, 296. 
Milk-abscess, 264. 

Mind, affections of, may retard labour, 175. 
Miscarriage, 122. 

N. 

Nipples, areola round, importance of, as a sign of pregnancy, 100. 
unfavourable management of, 260. 
flat, to be drawn out before labour takes place, 261. 
excoriation of, 261. 

how kept up, 261. 

treatment of, 262. 
tenderness of, how to be prevented, 263. 



O. 

Os uteri, slow dilatation of, 138, 179. 
rigidity of, 179. 
soft or cedematous, 179. 
sometimes lost by sloughing, 182. 
Ova, passage of, into the uterus, 82. 
Ovaries, dropsy of, 74. 

characteristic symptoms of, 74. 
kinds of fluid in, 75. 
quantity of fluid in, 75. 
progress of, 75. 

tapping for the relief or cure of, 75. 
treatment of, 76. 
Ovum, when to be discovered in the uterus, 91. 
anatomy of, 91. 

43 



334 INDEX. 

P. 

Pains, false or spurious, 142. 

how discriminated, 143. 
spurious, how to be treated, 143, 180. 
Patient in labour, when to be left, 145. 
Pelvis, anatomy of, 139. 
axes of, 140= 
dimensions, 183. 
deformity of, 183. 

cause of, 184. 
how known, 207. 
curved spine no proof of, 207. 
with arm presentation, 213. 
too great to admit the passage of the body 
after craniotomy, 216. 
Perinaeum, lacerated, 52. 

how produced, 52. 
varieties of, 53. 
how prevented, 54. 
when to be supported, 146. 
Peritonitis, puerperal, how distinguished from after-pains, 269. 
Peritoneal inflammation, frequent after puerperal convulsions, 274. 
Pessaries, different kinds of, 66. 
Pessary, how introduced, 67. 

Phlegmasia alba dolens puerperarum, symptoms and stages of, 283. 

pathognomonic sign of, 284. 
origin and termination of, 284. 
treatment of, in its several stages, 285. 
connected with an irritated state of 

the uterus, 286. 
has been produced by tying a poly- 
pus of the uterus, 286. 
description and treatment of a disease 
resembling, 286. 
Placenta, anatomy of, 92. 

on the management of, 149. 
danger of the separation of, 150. 

averted by contraction of the uterus, 150. 
separation of, to be left to nature, 150. 

how ascertained, 151. 
when to be removed, 152. 
how to be extracted, 153. 
danger of separating from the uterus, 152. 
circumstances requiring the separation of, 153. 
methods of separating from the uterus, 163. 



index. 335 

Placenta, adhesion of, 165. 

how to be separated in cases of, 166. 
retention of, 170. 
retained, removal of, 171. 

when to be removed, 171. 
presentation of, 241. 

women not to be left in cases of, 243. 
how to be ascertained when doubtful, 245. 
management of, in twin cases, 248. 
Polypus uteri, 55. 

diagnosis of, 56. 
origins of, 57. 
treatment of, 57. 
operation for, 57. 

caution to be observed in tightening the 
ligature for, 58. 
Position, change of, in footling cases, how accomplished, 218. 
Posture, recumbent, how long to be preserved after labour, 258. 
Pregnancy, on, 78. 

state of the abdomen in, 87. 

signs of, 99. 

order of symptoms of, 100. 

how far to be depended on, 101. 
when to be ascertained, 102. 
how ascertained, 103. 

how distinguished from some diseases, 104. 
diseases of, 106. 

affections of the head during, 107. 
dyspnoea during, 108. 
haemorrhage from the lungs during, 108. 
Pregnancy, costiveness during, 112. 

effects of, 113. 
violent motions of the child during, 113. 
oedema of the lower extremities during, 113. 
varicose state of the veins during, 115. 
Presentation, how ascertained, 142. 
Presentations, preternatural, 217. 

varieties of, 217. 
Presentations, preternatural, distinguishing marks of, 217. 
Prolapsus uteri, 62. 
Propagation, different modes of, 78. 
Pruritus pudendi, 45. 

treatment of, 46. 
Pubis symphysis, section of, 214. 
Pudenda, itching of, during pregnancy, 115. 



336 INDEX. 

Puerperal fever, 267. 
mania, 277. 
Purgative to be given the third day after labour, 257. 

Q. 

Quickening, 100. 

R. 

Retroversio uteri, 116. 

fatal terminations of, 117. 
how ascertained, 118. 
cause of, 118. 
treatment of, 119, 120. 

S. 

Shields for nipples, how to be employed, 262. 

Sickness during pregnancy, 108. 

Sides, pain in, during pregnancy, 111. 

Soft parts, sloughing of, 118. 

Spina bifida, 304. 

Stools, green, in infants, 306. 

Syncope from uterine haemorrhage, 168. 

Swelled leg of lying-in women, 283. 

T. 

Teeth, growth of, 315. 

Teething, disorders connected with, 313. 

general account of, 313. 
Transfusion of blood, note on, 238. 
Turning the child, object of, 222. 

when to be performed, 222. 
bleeding and laudanum to facilitate, 224. 
how performed, 224, 225. 
which hand to be employed in, 224. 
place of the feet at the time of, how known, 225. 
when to be performed in cases of uterine haemorrhage, 239. 
Twin cases, how frequent, 245. 

how ascertained, 243. 

management of, 247. 

patients not to be left in, until completely delivered, 

247. 
danger of removing the placenta in, 247. 
delivery of the second child in, how promoted, 247. 



index. 337 

Twin cases, danger of haemorrhage in, 247. 

with preternatural presentations, 248. 
delivery of the second child in, when to be per- 
formed, 248. 
management of the placenta in, 248. 

U. 

Umbilicus, defects of, 300. 

Urethra, defects of, relatively to impregnation, 86. 

imperforate in the male infant, 302. 
Urine, retention of, after labour, 254. 
Uteri procidentia, 62. 

common cause of, 62. 
varieties of, 63. 
stomach affected by, 63. 
symptoms of, 64. 
how best ascertained, 64. 
treatment of, 65, 66. 
when curable, 67. 

mistaken for disorder of the stomach, 68. 
in what manner frequently produced, 258. 
cervix, when obliterated in pregnancy, 103. 

obliteration of, during pregnancy, 237. 
retro versio, 116. 

fatal termination of, 117. 
how ascertained, 118. 
cause of, 118. 
treatment of, 119. 
Uterus, chronic inflammation of, 69. 

treatment of, 69. 
cancer of, 70. 

varieties and symptoms of, 71. 
period of occurrence of, 72. 
progress of, 72. 
medical treatment of, 72. 
removal of, 73. 
gravid, 86. 

changes of, after impregnation, 87. 
during pregnancy, not enlarged by distention, 88. 
thickness of, 88. 
vessels of, 89. 

principally concerned in haemorrhage from, 89. 
membrane lining, during pregnancy, 89. 
contraction of, on the separation of the placenta, 151. 
when easily inverted, 153. 



338 INDEX. 

Uterus, irregular contraction of, after the birth of the child, 157. 
means of exciting the contraction of, 158. 
best method of exciting contraction of, and of compress- 
ing, 158. 
hour-glass contraction of, 163. 
inflammation of, during labour, 189. 
danger of lacerating, in turning the child, 224. 
rupture of, how produced, 248. 

most frequent place of, 248. 
symptoms of, 248. 
by the hand or by instruments, 249. 
state disposing to spontaneous, 249. 
from sloughing, 250. 

fatal case of, 250. 
not always fatal, 251. 
common consequences of, 250. 
whether to be anticipated and prevented, 251. 
management of cases of, 251. 
favourable termination of case of, 252. 
considerably inflamed in puerperal fever, 269. 
inflammation of, causes of, 276. 

how distinguished, 276. 

from puerperal peri- 
tonitis, 276. 
appearances after death from, 276. 
often combined with peritonitis, 276. 
inversion of, how commonly produced, 286. 
degrees and symptoms of, 287. 
how to be ascertained, 287. 

in its different degrees, 288. 
haemorrhage from, 288. 
danger of, 289. 
consequences of, 288. 
chronic, 289. 

management of, 290. 
inverted to be immediately reduced, 289. 

can be reduced with certainty only at the moment 
of its occurrence, 289. 
reduction of, in its several degrees, 290. 
how accomplished, 289. 
contraction of the uterus after, 290. 
management of, when the placenta is still at- 
tached, 290. 
how to be returned when protruding through the 
labia, 291. 



INDEX. 339 

Uterus, reduction of, to be pressed up in the axis of thepelvis, 291 . 
removal of, 292. 
not necessary to the sexual passion, 292. 

V, 

Vaccination of infants, 297, 298. 
Vagina, malformed, 51. 

treatment of, 55. 
variety of, 51. 
sloughing of, 51. 
fistulous communication of, with the bladder, treatment 

of, 54. 
adhesions in, 182. 
Vectis, employment of, 205. 

employment of, different modes of, 205. 
applicable to what cases, 206. 
application of, 206. 
Veins, varicose during pregnancy, 116. 
Vesiculse Grafnana, 80. 

W. 

Watery gripes, symptoms and treatment of, 308. 

mortality from, in London, 309. 
Weaning, when proper, 314. 
Wet-nurse, what to be chosen, 296. 

advantages of, in diseases of infants, 307. 
Women, management of, after delivery, 253. 

not to be moved soon after delivery, 253. 
dress proper for, during labour, 254. 
how often to be visited after labour, 258. 
when first to go out after labour, 259. 
diseases of, after delivery, 267. 

neither menstruate nor conceive in general, when suck- 
ling, 317. 



THE END. 



[Philadelphia, June, 1841.] 

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EPIDEMICS of the MIDDLE AGES. 
From the German of I. F. C. Hecker, 
M.D., &c. &c. Translated by R. G. 
Babington, M.D. F.R.S. — 



Articles in the Library and Eclectic Journal of Medicine. 



9. No. T.— THE BLACK DEATH IN 

THE 14th CENTURY. 
" Becker's account of the ' Black Death,' which 
ravaged so large a portion of the globe in the 
fourteenth century, may be mentioned as a work 
worthy of our notice, both as containing many 
interesting details of this tremendous pestilence, 
and as exhibiting a curious specimen of medical 
hypothesis."— Cyclopedia of Practical Medicine- 
History of Medicine by Dr. Bostock. 

10. No. II.— THE DANCING MANIA. 

'•Medical History has long been in need of the 
chapter which this book supplies; and the defi- 
ciency could not have been remedied at a better 
season. On the whole, this volume ought to be 
popular; to the profession it must prove highly 
acceptable, as conveying so much information, 
touching an important subject which had almost 
been suffered to be buried in oblivion, and we 
think that to Dr. Babington especial thanks are 
due for having naturalised so interesting a pro- 
duction. The style of the translation, we may 
add, is free from foreign idioms : it reads like an 
English original."— Land. Med. Gat. 

11. LECTURES on Subjects connected 
with CLINICAL MEDICINE. By 
P. M. Latham, M.D. Fellow of the 
Royal College of Physicians, and Phy- 
sician to St. Bartholomew's Hospital. 



" We strongly recommend them [Latham's 
LecturesJ to our readers; particularly to pupils 
attending the practice of our hospitals."— Land 
Med. Oaz. 

12. ELEMENTS OF SURGERY, in 

Three Parts. By Robert Liston, Fel- 
low of the Royal College of Surgeons 
in London and Edinburgh, Surgeon to 
the Royal Infirmary, Senior Surgeon 
to the Royal Dispensatory for the City 
and County of Edinburgh, Professor of 
Surgery in the London University, &c. 
&c 
" In the present work, an endeavour has been 
made, in the first place, to lay down, correctly 
and concisely, the general principles which ought 
to guide the Practitioner in the management of 
constitutional disturbance, however occasioned. 
" The observations introduced to illustrate the 
doctrines inculcated, are given as briefly as is 
consistent with an accurate detail of symptoms 
and results. The descriptions of particular dis- 
eases have been sketched and finished from na- 
ture ; and, it is hoped, with such fidelity, that 
their resemblance will be readily recognized. 

" Such modes of operating are described, as 
have been repeatedly and successfully performed 
by the Author." 



JOURNAL DEPARTMENT. 

In the ECLECTIC JOURNAL OF MEDICINE, Vol. I., or First Year, 

HAVE BEEN PUBLISHED, 

Original Articles on Retrospection in Medicine, Clinical Medicine, Medical 
Education, Medical College of Philadelphia, Phrenology, &c. Numerous 
articles on Physiology, Pathology, Therapeutics, Midwifery, Surgery, and 
Hygiene, embracing new views of disease and modes of practice. Revieivs of 
new Works, &c. &c. 



5n the Library, Secorad Tear, 

FROM NOVEMBER, 1837, TO OCTOBER, 1838, 



HAVE BEEN PUBLISHED, 



1. A PRACTICAL TREATISE ON 
DISEASES OF THE SKIN, ar- 
ranged with a view to their Constitu- 
tional Causes and Local Character, &c. 
By SAMUEL PLUM BE, late Senior 
Surgeon to the Royal Metropolitan In- 
firmary for Children, &c. Illustrated 
with Splendid Coloured Copperplate 
and Lithographic Engravings. 

"This work, which has long been a standard 
on Cutaneous Diseases, is, in this new edition, 
brought down by the Author to the present state 
of our knowledge; a clear compendium is pre- 
sented of the recent discoveries of Chevallier. 
Breschet, and Vauzeme. The illustrations of 
cutaneous disease are happily exhibited, and are 
essential accompaniments. It is an able, in- 
structive, and elaborate production, and indis 
pensable to the medical man." — Innals of Medi- 
cine, January, 1837. 

Pldmee on Diseasen of the Skin.—" This excel- 
lent Treatise upon an order of diseases, the pa- 



thology of which is, in general, as obscure as the 
treatment is empirical, has just been republished 
in the Select Medical Library, edited by Dr. John 
Bell, of this city. We hail with pleasure the 
anpearance of any new work calculated to elu- 
cidate the intricate and ill -understood subject of 
skin-diseases. The late Dr. Mackintosh, in his 
Practice of Physic, recommends it as the 'best 
pathological and practical treatise on this class 
of diseases, which is to be found in any lan- 
guage.' " — Phil- Med. Exam., Jan. 17, 1838. 

"This work is one of the most excellent on 
the Diseases of the Skin, in the English lan- 
guage." — West. Jour, of Med. and Phys. Sciences, 
Jan. 1838. 

2. THE MEDICAL PROPERTIES of 
the NATURAL ORDER RANUN- 
CULACE.-E, &c. &c. By A. Turn- 
bull, M.D. 

3. THE GUMS ; with late Discoveries on 
their Structure, Growth, Connections, 
Diseases, and Sympathies. ByGEORGE 

15 



Catalogue of Works published in the Select Medical Library, 



Waite, Member of the London Royal 
College of Physicians. 

4. A PRACTICAL TREATISE ON 
MIDWIFERY; Containing the Re- 
sults of Sixteen Thousand Six Hun- 
dred and Fifty-four Births, occurring in 
the Dublin Lying-in Hospital. By Ro- 
bert Collins, M.D., Late Master of 
the Institution. 

" Several reprints of great value have already 
appeared in the Library— among others, Prich- 
ard on Insanity, Curling on Tetanus, Latham's 
Clinical Lectures, &c. The Number for the pre- 
sent month commences Collins's Treatise on 
Midwifery, a work rich in statistical details." — 
Phil. Med. Exam., Jan. 17, 1838. 

" The seventeenth Number of Dr. Bell's Select 
Medical Library contains the conclusion of ' A 
Practical Treatise on Midwifery, by Robert Col- 
lins, M.D., Fhysician of the Dublin Lying-in 
Hospital.' — The author of this work has em- 
ployed the numerical method of M. Louis; and 
by accurate tables of classification, enables his 
readers to perceive, at. a glance, the conse- 
quences of the diversified conditions, in which 
he saw his patients. Avast amount of informa- 
tion is thus obtained, which is invaluable to 
those who duly appreciate precision in the ex- 
amination of cases." — Bait. Chron. 

5. A PRACTICAL TREATISE ON 
THE MANAGEMENT AND DIS- 
EASES OF CHILDREN. By Rich- 
ard T. Evanson, M.D., Professor of 
Medicine, — and Henry Maunsell, 
M.D. Professor of Midwifery, — in the 
College of Surgeons in Ireland. 

"The authors of the work before us, have had 
the advantage of investigating the subject of 
Infantile Diseases, conjointly in a public insti- 
tution— an advantage which no private medical 
man, however extensive his practice, could pro- 
bably have. The observations being made con- 
jointly too, offer a greater guarantee of correct- 
ness and authenticity, than if they emanated 
from a single source, however respectable. From 
their acquaintance, also, with foreign works, 
they have been able to bring up the Anatomy. 
Physiology, Pathology, and even Therapeutics, 
to a far higher level than is to be found in any 
previous work in the English language. 

" The second chapter embraces the Manage- 
ment and Physical Education of Children. This 
chapter ought to be printed in gold letters, and 
hung up in the nursery of every family. It 
would save many lives, and prevent much suf- 
fering." — Medico- Chirurg. Rev. 

"We know of no work to which, on the 
whole, so little can be objected in matter or 
manner. It is an elegant and practical com- 
pendium of Infantile Diseases; a safe guide in 
the Management of Children ; and completely 
fulfils the purposes proposed."— British Annals 
of Medicine, No. VIII. 

6. THE SURGEON'S PRACTICAL 
GUIDE IN DRESSING, and in the 
Methodic APPLICATION of BAND- 
AGES. Illustrated by one hundred 

ENGRAVINGS. By THOMAS ClTTLEK.M.D. 

late Staff Surgeon in the Belgian Army. 
"Cutler on Bandages, with one hundred il- 
lustrative Engravings, will be invaluable to the 
great majority of the profession, throughout this 
country. But few have had the opportunity 
which a large hospital only affords, of becoming 

16 



acquainted with the best mode of applying ap- 
paratus, in cases of wounds, fractures, disloca- 
tions, &c. The plates and descriptions of this 
work, give this important information." — Bait. 
Chron. 

7. ON THE INFLUENCE OF PHY- 
SICAL AGENTS ON LIFE. By 
W. F. Edwards, M.D., F.R.S., etc. 
Translated from the French, by Drs. 
Hodgkin and Fisher. To which are 
added, some Observations on Electri- 
city, and Notes to the work. 

" This is a work of standard authority in 
Medicine ; and, in a physiological point of view, 
is pre-eminently the most valuable publication 
of the present century ; the experimental inves- 
tigation instituted by the author, having done 
much towards solving many problems hitherto 
but partially understood. The work was origi- 
nally presented in parts to the Royal Academy 
of Science of Paris, and so highly did they esti- 
mate the labours of the author, and so fully ap- 
preciate the services by him thus rendered to 
science and to humanity, that they awarded 
him, though a foreigner, the prize founded for 
the promotion of experimental physiology. 

" His researches relate to what are denomi- 
nated the Physical Agents, viz: Temperature, 
as modified in degree and duration; Electricity ; 
Air, as regards quantity, motion or rest, density 
or rarity ; Water, as a liquid and in a state of 
vapour; and Light; and his object is to show 
the effects produced on the human system by 
these agents which surround and are incessantly 
exercising an influence upon us. 

" It is hardly necessary for us to say, that the 
design has been executed in a masterly man- 
ner, and that the profession is under deep obliga- 
tions to Dr, Edwards, for so satisfactorily per- 
forming his task, and furnishing it with such a 
body of facts, and such a vast number of experi- 
ments, in illustration and confirmation of his 
views." — Prov. Jour. 

8. Prof. HORNER'S NECROLO- 
GICAL NOTICE OF DR. P. S. 
PHYSICK; Delivered before the 
American Philos. Society, May 4, 

1838. 

9. ESSAYS ON PHYSIOLOGY 
AND HYGIENE; viz: 

I. REID'S EXPERIMENTAL IN- 

VESTIGATION into the FUNC- 
TIONS of the EIGHTH PAIR 
OF NERVES. 

II. EHRENBERG'S MICROSCO- 
PICAL OBSERVATIONS on the 
BRAIN AND NERVES (with 

NUMEROUS ENGRAVINGS). 

III. ON THE COMBINATION OF 
MOTOR and SENSITIVE NER- 
VOUS ACTIVITY; by Professor 
Stromeyer, Hanover. 

IV. VEGETABLE PHYSIOLOGY. 

V. EXPERIMENTS ON THE 
BRAIN, SPINAL MARROW, 
and NERVES. By Prof. Mayer, 
of Bonn (with woodcuts). 



and of Articles in the Eclectic Journal of Medicine. 



VI. PUBLIC HYGIENE. 

VII. PROGRESS of the ANATO- 
MY and PHYSIOLOGY of the 
NERVOUS SYSTEM, during 
1836, By Professor Muller. 

VIII. VITAL STATISTICS. 

10. CURIOSITIES OF MEDICAL 
EXPERIENCE. By J. G. Mil- 
lingen, Surgeon to the Forces, 
Member of the Medical Society of 
the Ancient Faculty of Paris, etc., 
etc. 

" Curiosities of Medical Experience. By J. G- 
Millingen, Surgeon to the Forces, etc. The 
Author or Compiler derived the idea which 
prompted him to write this work from Disraeli's 
'Curiosities of Literature;' and, in our view, 
he has made a book equally curious in its way 
with that one. The heads of his chapters are 
numerous and varied; and all his subjects are 
treated in an agreeable and comprehensible 



style to the general reader. The drift of the 
Author, too, is decidedly useful. We shall en- 
deavour to give some extracts from this work." 
—JVat. Gat. 

11. MEDICAL CLINIC; or, Re- 
ports of Medical Cases: By G. 
Andral, Professor of the Faculty 
of Medicine of Paris, etc. Con- 
densed and Translated, with Obser- 
vations extracted from the Writings 
of the most distinguished Medical 
Authors: By D. Spillan, M.D., 
etc., etc. ; containing Diseases of the 
Encephalon, &c, with Extracts from 
Ollivier's Work on Diseases of the 
Spinal Cord and its Membranes. 

12. AN ESSAY ON DEW, and several 

Appearances connected with it; by 
William Charles Wells, M.D 
F.R.S., etc. 



JOURNAL DEPARTMENT. 

In the ECLECTIC JOURNAL OF MEDICINE, Vol. II., or Second Year, 

HAVE BEEN PUBLISHED, 

Original Articles on Animal Magnetism, Laryngeal Phthisis, Elephantiasis, 
the Use and Abuse of the Pessary, Dislocation of the Elbow Joint, Lithotripsy, 
Pneumonia Typhoides, Excision of the Neck of the Uterus, the Plague of 
Athens, translated from the Greek of Thucydides; the Application of Turpen- 
tine in Tetanus, Medical Schools and Professorships, the Use of the Balsam of 
Copaiba in Diseases of the Mucous Membrane of the Intestinal Canal, on an 
Improved Auriscope — with engraving; the Solar Speculum — with engraving, 
&c. ; Digests and Reviews of several new Works. Numerous Articles on Phy- 
siology, Chemistry, Pathology, Therapeutics, Midwifery, Surgery, and Hygiene, 
with an Index and Title-pa?;e, — forming a handsome volume of near^we hundred 
closely printed pages ; which, with the LIBRARY, amounts to near THREE 
THOUSAND pages for TEN DOLLARS; containing as much matter, (and 
that selected from the best authors,) as in ordinary medical works would occupy 
five thousand pages, or twelve volumes. 



In the library, Third Year, 

COMMENCING NOVEMBER, 18.38, AND ENDING OCTOBER, 1839, 



1. 



HAVE BEEN PUBLISHED, 



LECTURES ON THE PHYSIO- 
LOGY AND DISEASES OF THE 
CHEST; including the Principles of 
Physical and General Diagnosis. De- 
livered during the Spring Sessions of 
1836 and 1837, at the Anatomical 
School, Kinnerton Street, near St. 
George's Hospital. By Charles J. B 
Williams, M.D., F.R.S. Professor of 



the Principles and Practice of Medicine 
in University College, London. With 
Engravings. 

ESSAY UPON THE QUESTION, 
IS MEDICAL SCIENCE FAVOR- 
ABLE TO SCEPTICISM ? By 
James W. Dale, M.D., of Newcastle, 
Delaware, 

17 



Catalogue of Works published in the Select Medical Library, 



3. LECTURES ON THE PRINCI- 
PLES OF SURGERY. By John 
Hunter, F.R.S. With Notes by 
James F. Palmer, Senior Surgeon to 
the St. George's and St. James's Dispen- 
saries, &c. &c. With Plates. 

" We have perused these lectures with no or- 
dinary feelings of satisfaction. They embody an 
immense amount of important facts, directed 
with no common skill to the illustration and 
improvement of medical science generally, and 
of the surgical department in particular. Indeed 
we have no hesitation in saying, that, whatever 
be the position of the reader in the profession, he 
will not relinquish the perusal of these lectures 
without the consciousness of having usefully 
employed the time which he may have bestowed 
upon them. For they constitute, in the fullest 
sense of the term, a philosophical disquisition on 
the science of Surgery; and hence, embracing 
the great principles on which the whole art of 
healing rests, their interest will be felt by~all 
who regard Medicine as a true branch of science, 
and who delight to witness the gradual develop- 
ment of principles in the right interpretation of 
the phenomena of nature." 

"We cannot bring our notice of the present 
volume to a close without offering our testimony 
to the admirable manner in which the editor and 
annotator has fulfilled his part, of the underta- 
king. The advancements and improvements 
that have been effected, up to our own day, not 
only in practical surgery, but in all the collate- 
ral departments, are constantly brought before 
the reader's attention in clear and concise 
terms."— Brit. $■ For. Med. Rev. 

" Tne surgical lectures alone were sufficient 
to fix us long in our chair, and our pains were 
amply compensated by the perusal of the very 
words in which Hunter had instructed his class." 

" The rescuing of these lectures from that ob- 
livion which they must needs have fallen into in 
private hands, alone constitutes the editor of 
Hunter's works a benefactor to the student and 
the scholar."— Medical Gazette. 

4. ON DENGUE; ITS HISTORY, PA- 
THOLOGY, AND TREATMENT. 
By S. Henry Dickson, M.D., Pro- 
fessor of the Institutes and Practice of 
Medicine in the Medical College of S.C. 

5. OUTLINES OF GENERAL PA- 
THOLOGY. By George Freckle- 
ton, M.D., Fellow of the Royal College 
of Physicians. 

6. URINARY DISEASES and their 
TREATMENT. By Robert Wil- 
lis, M.D.. Physician to the Royal In- 
firmary for Children, &c. <fcc. 

"We do not know that a more competent au- 
thor than Dr. Willis could have been found to 
undertake the task ; possessing, as it is evident 
from his work that he does possess, an accurate 
acquaintance with the subject in all its details, 
considerable personal experience in the diseases 
of which he treats, capacity for lucid arrange- 
ment, and a style of communication commenda- 
ble in every respect." 

"Our notice of Dr. Willis's work most here 
terminate. It is one which we have read and 
trust again to read with profit. The history of 
discovery is successfully given; casescurious and 
important; illustrative of the various subjects 
have been selected from many new sources, as 
well as detailed from the author's own experi- 

18 



ence, chemical analyses, not too elaborate, have 
been afforded, which will be most convenient to 
those who wish to investigate the qualities of 
the urine in disease; the importance of attend- 
ing to this secretion in order to a proper under- 
standing ot disease is strongly insisted upon; in 
short, a book has been composed, which was 
much required, and which we can conscientious, 
ly and confidently recommend as likely to be 
useful to all classes of practitioners. — Brit, (jj- 
For. Med. Rev. 

7. LECTURES on BLOOD-LETTING. 
By Henry Clutterbuck, M.D. 

8. THE LIFE OF JOHN HUNTER, 
F.R.S. By Drewry Ottley. 

"In the summing up of Mr. Hunter's character, 
Mr. Ottley exhibits equal judgment and can- 
dour." — Brit. S^ For. Med. Rev. 

9. HUNTER'S TREATISE ON THE 
VENEREAL DISEASE. With Notes 
by Dr. Babington. With Plates. 

"Under the hands of Mr. Babington, who has 
performed his task as editor in a very exempla- 
ry manner, the work has assumed quite a new 
value, and may now be as advantageously 
placed in the library of the student as in that of 
the experienced surgeon.— Brit. # For. Med. Rev. 

" The notes, in illustration- of the text, con- 
tain a summary of our present knowledge on 
the subject ; the manner in which these notes 
areconstructed is at once clever and perspicuous; 
and the modes of treatment, prescribed, spring 
from a right apprehension of the disease. We 
would recommend to the reader the note on the 
primary venereal sore ; the note itself is an es- 
say in every word of which we fully concur." — 
Med. Gazette. 

10. A TREATISE ON THE TEETH. 
By John Hunter. With Notes by 
Thomas Bell, F.R.S. With Plates. 

" The treatise on the teeth is edited by Mr. 
Bell, a gentleman accomplished in his art. Mr. 
Bell has studied his subject with the greatest mi- 
nuteness and care; and in appropriate notes at 
the first of the page corrects the author with 
the air of a gentleman, and the accuracy of a 
man of science. The matter contained in these 
short notes forms an ample scholum to the text ; 
and without aiming at the slightest. display of 
learning, they at the same time exhibit a ready 
knowledge on every point, and an extensive in- 
formation both of comparative anatomy and 
pathology.— Med. Gazette. 

11. MEDICAL AND TOPOGRAPHI- 
CAL OBSERVATIONS upon the 
MEDITERRANEAN and upon POR- 
TUGAL, SPAIN, AND OTHER 
COUNTRIES. By G. R. B. Hor- 
ner, M.D., Surgeon U. S. Navy, and 
Honorary Member of the Philadelphia 
Medical Society. W^ith Engravings. 

" An uncommonly interesting book is present- 
ed to those who have any disposition to know 
the things medical in Portugal, Spain, and 
other countries," and ' will doubtless be read, 
also, with marked satisfaction by all who have 
a taste for travels."— Bost. Med. and Surg. Jour. 

12. LECTURES ON THE BLOOD, 
and on the CHANGES which it 
undergoes during DISEASE. By 
F. Magendie, M.D. 



and of Articles in the Eclectic Journal of Medicine. 



JOURNAL DEPARTMENT. 

In the ECLECTIC JOURNAL OF MEDICINE, Vols. III., IV., or 
Third and Fourth Years, 1838-40, have been published, 

Original Reviews and Bibliographical Notices, viz., of Hosack's Lectures 
on the Theory and Practice of Physic, Walker on Intermarriage, the Works of John 
Hunter, Introductory Lectures, Granville on Counter-Irritation, Gallop's Outlines 
of the Institutes of Medicine, Bouvier on Club Foot, Harris's Dental Surgery, 
Vimont on Human and Comparative Physiology, &c, &c: also, Selected Reviews 
of Lonsdale and Burke on Fractures, Foissac on the Influence of Climate, Le- 
canu and Denis on the Chemistry of the Blood, Gondret &c. on Counter-Irrita- 
tion, &c, &c: Papers on Club Foot, Yellow Fever, Pathology of the Ovaria, 
Extirpation of the Parotid Gland, Endermic Medicine, Simple Ulceration of the 
Stomach, Artificial Digestion, Diseases of the Kidneys, Diseases of the Spine, 
Irritable Bladder, Fibres of the Spinal Marrow, Experiments on theBlood, Galvanic 
Experiments on a Dead Body, &c, &c, and numerous other articles on Thera- 
peutics, Pathology, Surgery, and Midwifery. 

*** Each Volume of the JOURNAL contains above 500 pages of closely 
printed matter. 



In the liiferary, Fourth ITeai*, 

COMMENCING NOVEMBER 1839, AND ENDING OCTOBER 1840, 

HAVE BEEN PUBLISHED, 



1. MEDICAL NOTES AND REFLEC- 
TIONS. By Henry Holland, M.D., 
F.R.S., Fellow of the Royal College of 
Physicians, and Physician Extraordi- 
nary to the Queen. 

2. CLINICAL REMARKS ON SOME 
CASES OF LIVER ABSCESS PRE- 
SENTING EXTERNALLY. By 

John G. Malcolmson, M.D. Surgeon 
Hon. E. I. C. Service, Fellow of the 
Royal Asiatic Society, and the Geolo- 
gical Society, London. 

3. HISTORICAL NOTICES ON THE 
OCCURRENCE OF INFLAMMA- 
TORY AFFECTIONS OF THE IN- 
TERNAL ORGANS AFTER EX- 
TERNAL INJURIES AND SUR- 
GICAL OPERATIONS. By Wil- 
liam Thompson, M.D., &c. &c. 

4. A EXPERIMENTAL INVESTI- 
GATION INTO THE FUNCTIONS 
OF THE EIGHTH PAIR OF 
NERVES. By John Reid, M.D., &c. 

5. TREATISE ON THE BLOOD, IN- 

FLAMMATION, AND GUN-SHOT 
WOUNDS. By John Hunter, F.R.S. 
With Notes, by James F. Palmer, 
Senior Surgeon to the St. George's 
and St. James's Dispensary, &c, &c. 



6. A PRACTICAL TREATISE ON 

VENEREAL DISORDERS, AND 
MORE ESPECIALLY ON THE 
HISTORY AND TREATMENT OF 
CHANCRE. By Philippe Ricord, 
M.D., Surgeon to the Venereal Hos- 
pital at Paris. 

7. A TREATISE ON INFLAMMA- 
TION. By James Macartney, F.R.S. , 
F.L.S., &c, Asc. Member of the Royal 
College, of Surgeons, London, &c, &c. 

8. AMUSSAT'S LECTURES ON 
THE RETENTION OF URINE, 
CAUSED BY STRICTURES OF 
THE URETHRA, and on the Diseases 
of the Prostate, translated from the 
French by James P. Jervey, M.D. 

9. OBSERVATIONS ON CERTAIN 
PARTS OF THE ANIMAL CECON- 
OMY, Inclusive of several papers from 
the Philosophical Transactions, &c. By 
John Hunter, F.R.S. , &c, &c. With 
Notes by Richard Owen, F.R.S. 

" One distinctive feature of the present edition 
of Hunter's works has been already mentioned, 
viz: in the addition of illustrative notes, which 
are not thrown in at hazard, butare written by 
men who are already eminent for their skill and 
attainments on the particular subjects which 
they have thus illustrated. By this means, whilst 
we have the views entire of John Hunter in the 

19 



Catalogue of Boohs, Terms of Subscription, etc. 



text, we are enabled by reference to the accom- 
panying notes, to see wherein the author is borne 
out by the positive knowledge of the present day, 
or to what extent his views require modification 
and correction. The names of the gentlemen 
who have in this manner assisted Mr. Palmer, 
are guarantees of the successful performance of 
their task." 

10. HINTS ON THE MEDICAL "EX- 
AMINATION OF RECRUITS FOR 
THE ARMY; and on the Discharge 
of Soldiers from the Service on Sur- 
geon's Certificate : Adopted to the Ser- 
vice of the United States. By Thomas 
Henderson, M. D., Assistant Surgeon 
U. S. Army, &c, &c. 

K ESSAY ON HYSTERIA; being 

h tnalysis of its irregularandaggravated 

forms; including Hysterical Hemorrhage 



and Hysterical Ischuria. With numer- 
ous Illustrations and Curious Cases. 
By Thomas Laycock, House Surgeon 
to the York County Hospital. , 

12. A TREATISE ON THE CAUSES 
AND CONSEQUENCES OF HABI- 
TUAL CONSTIPATON. By John 
Burne, M.D., Fellow of the Royal Col- 
lege of Physicians, Physician to the 
Westminster Hospital, &c. &c. 

" For some interesting cases illustrative of this 
work, the author is indebted to Dr. Williams, Dr. 
Stroud, Dr. Callaway. Mr- Morgan, Mr. Taunton, 
Dr. Roots, Sir Astley Cooper, Sir Benjamin Brodie, 
Mr. Tupper. Mr. "Bailer, Dr. Paris, Mr. Dendy, 
Dr. Hen. U. Thomson," &c— Preface. 

13. A TREATISE ON MENTAL DIS- 
EASES. By M. Esquirol. 



0^7= The Works published in either year, as enumerated above, with the 
Eclectic Journal, ran be obtained bound in 6 vols, for $13; or, the whole 
Series, 24 volumes, bound in uniform style, for $52. 



TERMS OF SUBSCRIPTION 



THE SELECT MEDICAL LIBRARY, 



Published Quarterly, 
IN JANUARY, APRIL, JULY, AND OCTOBER. 

Each Number of the Library will consist of one or more approved works on 
some branch of Medicine, including, of course, Surgery and Obstetrics. 

Every work in the Library will be completed in the number in which it is 
begun, unless the subject naturally admits of division ; and hence the size of the 
numbers will vary. It will be done up in a strong paper cover, and each work 
labelled on the back; thus obviating the immediate necessity of binding. 

Subscribers will receive fourteen hundred pages of closely printed matter of 
Library in the year. 

To each number of the Library will be appended a Bulletin of Medical 
Science. 

FIVE DOLLARS per annum, in advance; and in no single instance, out of 
the chief cities, will this rule be departed from. 

Subscribers who wish to receive the Library direct from us must remit the amount 
of their subscription ,• as none of our agents are authorized to receive money on our 
account ; nor will we hold ourselves responsible for any defalcations on their part. 
HASWELL, BARRINGTON, AND HASWELL, 

Publishers, 293 Market Street, Philadelphia. 



The attention of the Medical Faculty is respectfully invited to this Periodical. 
In the fifth year, which is now in course of successful publication, have been pub- 
lished, in the January number, A PRACTICAL DICTIONARY OF MATERIA 
ME D1C A, including the Composition, Preparation and Uses of Medicines ; and a 
iarge number of Extemporaneous Formulae : together with important Toxicological 
Observations ; on the Basis of 'Brandt 1 's Dictionary of Materia Medica and Practical 
Pharmacy; by John Bell, M.D., Lecturer on Materia Medica and Thera- 
peutics, &c. &c. ; and in the April number, SchilPs Outlines of Pat ho logical Semi- 
ology, translated by D. Spillan, M.D., &c. &c. ; with Aretseus on the Causes and 
Sigm of Acute Disease.- — containing also, in the BULLETIN, Notices of New 
"Works, Medical Schools, and other valuable professional information. 
20 








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